illnesses, 55% of three or more. i also think that a lot of medicare beneficiaries have very similar levels of functional impairment. i mean, it's different but it's not so substantially different on chronic illness. it really involves really thinking about how you manage the cognitively or mentally impaired pause that's where the biggest difference between the dual eligible population and other medicare beneficiaries occurs. so in conclusion, we're really now looking at -- and melanie's alluded to being able to put together medicare and medicaid spending. in this analysis with the urban institute, within the dual eligible population are there some higher spenders and some who are lower. and we found if you look at top 10% of medicare spenders and 10% of medicaid spender there's are

somewhat different people though both dual eligibles and only 100,000 people fall into the category of being a high spender in both medicare and medicaid. and that's largely because, as we need to look forward at different ways to look at these populations, the subgroup analysis which melanie alluded to is so critical. you see that the top spenders in medicare are really top spenders because of their acute care utilization and those are services that medicare can and should be able to better control whereas the top spenders that end up on medicaid are often in nursing facilities and are also people who are using long-term care services in the community. and they actually spent a little less on acute care because their big spending is on long-term care. in conclusion, i think as we look at and try to figure out how to better manage both technology, where there's not a lot of it unfortunately on the

long-term care side, so most of the technology care would come in loo a need to also think of how to manage different types of chronically ill patients and how these programs can work together, better or work better with in each program for the chronically ill and that is where we see better outcomes and lower costs as we zoom in on the disability population and differences. >> thanks so much. bruce turn of, you have been speaking a lot about the same group discussing those with rising prevalence of chronic disease and engaged in the cost of those. what else do we need to know about this population? >> i want to pick up on where dianne left off. those last couple slides are incredibly important in our thinking here. as we wait for the slides to

come up, we are almost there. that looks good. terrific. as i begin my presentation i want to start in a similar place which is you have to look at folks who are getting care and what their needs are and that helps us think about better programs and this notion that the medicare and medicaid spenders is a critically important thing for everybody to take away today. my slide picks up on the point that those with chronic conditions that is only half the battle. those chronic conditions and functional limitations really drive a lot more of the high cost medicare spending and we will come to why that is so chronic conditions, we talk

about people and their diseases. the reality is function is an incredibly important piece of this. you care for yourself and medical context and personal context. when you factor in this notion of function. i want to pick up and turn it on its head. those people who were chronically ill. they still spend most of their time out and about in the world and that is not by hospital beds and doctor's offices and 3 aig centers. thinking of a role function place in disease is incredibly

important. how we build effective programs and target appropriately. this goes on to say when you add in functional impairment regardless of the product conditions, very important cost drivers in the lives -- regardless of the number of chronic conditions that they have. echoing off of the point that how do medicare and medicaid -- i know why you are here. this slide, who are the lead dewars and what this slide starts to raise is the issue -- what does a good tool program look like. when you look at individuals who have chronic illnesses and substantial functional limitations half of them -- they run the risk of spending down

and becoming duals. your financial resources than they might have had. this is the cost drivers over the next 10 or 15 years. when we start to talk with folks about what they really want we decided we would do almost 20 focus groups across the country last year and a series of calls. what we did was choose to talk with individuals who were 45 to 65 and inga caregiving world and those who were 65 plus who were care giving or care receiving this presents the work cloud that looks at the most important language folks used. it is important we look at this because these were all individuals who could

exquisitely describe the caregiving or care receiving process. i am a general internist by training. i love the medical system as much as the next guy but i offer you that there is very little medical stuff on this slide. with all due respect to a lot of the great programs you don't see this red with disease management, care, hospice. it goes to my earlier point which is function is incredibly important and individuals define themselves by the function. if you look at the words that are up there like community and independent, that is how people think of themselves. as we start to think of the kinds of solutions we want, why is this technology to work? the points are what is the problem we are trying to solve here? there is very level evidence

picking up on the earlier points. surgical robots at much value. the reality is -- the data that is available and marketing problems and if you are in a competitive environment is good to say you have a robot and my friends love them. it is keeping your medical staff intact. that is a different problem. solving a marking problem is different from a credible care coordination problem. when we looked at the population that has substantial medical problems but substantial functional limitations thinking carefully about the problem you are trying to solve is key and it may be more of it is a low-tech solver. the world of the telephone and pieces of technology that do work. things like medicine optimization are places where all little bit of technology can

go a long way. that is take home number one. we will introduce technology. what is the problem we are trying to solve? the second thing about technology is in this environment that i'm trying to build on technology is not an end to end solution. technology rarely solves any problems in this seriously chronically ill functionally limited person's life. it is a tactic, not a strategy. at an end of the day to introduce a piece of technology will give you nothing but costs and maybe more risks than benefits. most older individuals when they get sent home from a complicated hospital stay get technology and they dropped something off and if there isn't a substantial and robust care coordination plan driven by the family or the health care system or others that piece of technology and lenore -- may bring more risks than benefits. it gets to the point that technology without a good care

coordination plan is of questionable value. as we build systems, as we think about the work you are doing in the care coordination office it is not just about the medicare model of care and that nice model where we like to think about it. it is the mall of care coordination and personal central care coordination that will be at issue. as you look at the state's we are proposing and we encourage you to look hard not just that is their plan for the in and out of the nursing home but what is the plan of care that supports people towards retaining the function they have even if they have serious illness or functional loss. my last point picking up on one of the comments in the audience is this issue of targeting. targeting is really important. you are not going to solve -- diane slides into this. for the high spending medicare

population, medically oriented falls are probably going to take you a long way. the nice article that was published that covered this data sort of make the observation that that is the place where a medical home may make a lot of sense because you have folks with doctors and nurses and pharmacists and others coordinating the medical capps is half the battle. that is a good place to start but for the medicaid population where the need may be more functional than community-based the model of care may look different and the medical home may not be a solution because the problem with the medical home is we are glad to talk to you in a medical contacts. come in, we have the same data but for someone whose needs are more functional or socially related being drawn into the medical system may not be the solution. we encourage the technology and a targeted fashion. what is the problem you are trying to solve?

are we looking to solve a medical problem or a functional problem? thanks. >> thanks very much. now to susan reinhart. now we know who the chronically ill are and their needs are not all the same and we talk about consumer engagement or person engagement, why don't we bring those things together? >> if you left that because you wanted a patient perspective which i am happy to try to bring to this discussion -- can you hear me? is this on? so what i want to talk about is this idea that can does a good job in all of his work talking about the need for better patient and family self management and the need for pools for that. as we talk about who are the chronically ill, how they're spending their dollars, technology that is certainly going to have to be used by the

patient and family, what are the patients telling us in any model we might develop and use? a couple of years ago, at the public policy institute we conducted a national survey of location and family care givers. these are people with multiple chronic conditions experienced transitions. that is the focus of this work. we talked about what their experience was legal what their concerns were and to cut to the chase, many of these patients and caregivers talk about poor communication. as we are talking about technology and the use of patient self management tools many of them didn't know that they even existed. some of the data i want to share with you that i see as a challenge for what at the end of the day we have to confront which is one in four black confidents in the system a love their doctor or nurse

practitioner but the system is overwhelming to them. we know from other literature that the average person on medicare as two primary care physicians and five specialists across different practice settings. that has a lot to take on and have some confidence that this is going to work together. 30% said when they went to visit usually the doctor there was enough information to even have a conversation. 21% said the providers do not talk to wage other. this is where it gets to be very tricky. we talked about how important it is that patients adhere to their medical regimen but they get conflicting information. one in four saying they get different information to more clinicians and they feel their own health is suffering because of that. this is the one that really got me when i saw this.

27% admitted this is an admission on a survey where you know you don't want to admit things you are doing and these folks are saying they have not done something recommended by a health-care professional life get a prescription. most of them--32% said they didn't agree with what was being told. we need much more work and maybe some in this room know if there's more work on this. is a serious problem. we know adherence, more than 30 years of research on community dwelling builders and prescriptions for them, 25% of those prescriptions are inappropriate to begin with. and we know the polypharmacy is a huge deal. my argument for years is maybe it is a good thing many of these people are not adhering to. maybe they are saving their own lives. whatever we do we need to talk about this in a way that makes

sense to people. we also -- i didn't hear anybody talk about health literacy for example. a few years ago that was really hot. we need to come back to the health literacy issue. i remember one of the cases looked at this was a woman -- chronic care condition. a woman who was taking care of her child who had an ear infection and kept coming back and it was getting worse. if there was a liquid antibiotic she was putting in the year instead of the mouth because nobody showed her. she figured the year infection but the medication in that. and the work on hot spots for example in camden. there was a gentleman many of you know this particular case. it is very telling. a person with diabetes who kept coming back into the er. there was a certain pattern. someone said let me see you give

your insulin and why that wasn't done years before is beyond me. what he was doing was putting the -- he has a bottle on the table, putting the syringe in and pulling up instead of flipping the ball. the beginning of the prescription he was not getting the insulin he needed but as the insulin -- as he was just getting air and injecting air. it was a big revelation. now we know how to manage this person's condition. this to me is getting into a health work force the issue. as well as health care delivery. are we getting anticipatory guidance? it used to be fundamental to the arts and science of health care. talking about the technology, very deeply involved in communications and culture and outside of hospitals what goes on. we use to do anticipatory like you are going to find this is

going to happen and this is what you should be doing. we use to do peach back. show me how you are doing it. these interventions, the the basic skills that seem to have been lost, these were diverse caregivers and this is not uncommon. the federal worker, high-level federal worker for a number of years retired went to take his mother home from the hospital and they said you have to give these injections. he thought ok, i am going to go home. they must have been -- egos home and starts giving this, bruising the whole body not knowing what he is doing and wound up taking him back to the hospital in which case the health care team

in the emergency room said what have you been doing to your father? this is the experience of family caregivers. might have been good to show me how to do this. there's a lot going on trying to get to that point where we are talking about confidence, knowledgeable, skilled people who can be engaged but they got to understand what is happening to themselves. >> with that miraculously we have ended this part of the program almost exactly on time. let's take advantage of that and gto our break and we will come back for a very vigorous discussion where we tread these perspectives together and get some more discussion about actionable discussion. see you back here in 15 minutes.

can. ten minutes. >> the restaurants are around the corner. please do get back. [inaudible conversations] [inaudible conversations] >> welcome back, everybody. we are now going to move ahead and engage in some brisk discussion, exchange of views.

hopefully gravitation toward some actionable solutions that will make a difference in the rate of health costs at submitting growth and still give us the other things we want out of health care. just to briefly recap what we have heard so far this morning we heard from joseph antos that technology is a factor in terms of the supply and demand for it. there has been discussion about whether technology can be directly measured as a contributor to health costs. it is treated as a residual. the i don't know factor. if i can't explain it by others for other reasons i call it technology. nonetheless we can clearly see the role of technology and gave a number of historical examples of how technology has evolve over time. he offered a list of some

options some of which had some possible workability attached to them and others he was dubious about. one was comparative research. that not withstanding there is a lot we can do even within some of the constraints that exist in terms of the medicare program. mentioned coverage with evidence development not withstanding the fact that medicare is a political program. some of these changes could be made or tools could be used more effectively than they are now or at least some prospects of reining in some aspect of technology driven health spending growth we don't want and don't need. we heard from thorpe that 60% of the spending growth over the last couple decades has been attributable to the growing treatment of chronic disease. he was driven by rising obesity

whether it is diabetes or cardiovascular disease or other conditions that are linked to diabetes. he spent a good amount of time talking about the problems we encountered with lack of care coordination, lack of use of intervention that we know in each of the diabetes prevention programs and substantial evidence we have that loss of 5% to 7% of body weight can halt progression of free diabetes to diabetes that should be rather low-cost intervention that can be rolled out rather broadly. and care coordination in many respects he mentioned is a real force that could arrest some of the spending growth that has been attributed to those causes. we then heard from our reactors

in sequence. melanie bella talked about the dual eligibles who were poster children for the mix of chronic disease technology and cost and we heard about a number of pilots and their way to look at ways to improve the care of the individuals, decrease the turn back and forth between hospitals that cigarette the leaders lead reduced rate of costs. and we heard from joe newhouse that growth rates of as a problem ubiquitous across the world. notwithstanding the fact that the u.s. have a higher level, the real issue these other countries, the real issue is the rate of cost but as he mentioned nothing grows from the sky. there was her starring's famous comment that will not go on forever will stop. probably going to halt this

dramatic rate of growth. and we would love to hear you address whether we are in the midst of that, consumer directed health plans. and all the other things we know are a factor currently. we heard from james fasules about the beneficial aspects of a lot of the technology we adopted with respect to cardiovascular disease. and a 30% reduction and mortality of cardiovascular disease in the last decade. there are things going on in cardiovascular care that shouldn't be done or are done excessively that led to the acc recommendation about the five interventions not to allow your physician to suggest that you

have. as he noted, that coupled with a quality improvement efforts underway at various institutions improving the quality of cardiovascular care reducing some of the unnecessary care driven by a certain technologies. we heard from diane rowland that high spenders in medicare program are different from those in the medicaid program. a recipe for as developing a much more nuanced understanding about how to restrain excess costs in those two pockets of the population. we heard from bruce chernof on the same theme that half of the medicare enrollees with chronic conditions have functional limitations and half of them are dual eligibles but half are not. mindful of the problem we are trying to solve, the problem as

many patients see it is they lack of words he put up in his wonderful word cloud. they are not spending a lot of time thinking about how to get access to surgical robots. they are thinking about how to have independent dignified existence, independent of as many health-care providers as possible very often. then we heard from susan reinhart that patients and caregivers, a lot of the issues they face in health care is due to factors like for communication. they don't feel they are empowered sufficiently to make decisions with their health care providers. they are also clearly lacking in help literacy and she gave a number of examples underscoring that. and they too would like to engage in much more constructive dialogue with their health care providers how to have a care

system they really want that deliver on some of those wonderful words bruce mentioned. so with that the floor is open now for greater discussion about how we move forward in some of these issues together, continue to work on actionable solutions to press forward. joe, did you want to answer the question are tossed out at you before we get going? >> sure. i would distinguish began between the level of cost and the growth rate of costs, a phrase that was fashionable while back but i have not heard about a lot lately on growth rates. there is a lot of evidence that higher cost shaving in health plans would reduce the level.

there's not much evidence if any of growth rates. there is some evidence that the supply side interventions we are throwing out will affect levels. they could affect growth rates. i could make a theoretical case. there's not much evidence on that. so i don't want to make that sound terribly negative. at a minimum even if you just change the level and frees up resources for other activities. but since i think the growth rate is the issue exactly how to attack the growth rate, i think we are doing a lot of trial and error. it is fodder for future -- >> yes indeed. david? >> just to follow up on your question, understanding the differences between societies is

interesting. we have far and away the highest level of the growth rate, as far as policy prescription i am not sure there is quite as clear dichotomy. if you can knock 1% of the level by reducing chronic disease or improving care coordination for the next 20 years 1% the year than you got a growth rate. ..

we talked about this last month when we held us in this is something we talked about in our medical technical panel meeting, this level versus growth issue and we might be asking too much to say that something has a permanent long-term reduction in growth, and thinking more along the lines of this going to be a series shorter-term reductions that then, taken together, will bend the curve your so, you know, thinking about we can't expect one thing to have a permanent long, you know, term change of things. so how did we think about constantly evolving it and moving forward with new changes

over time? >> let me go a little further than david, where he just went. i'm not sure there's really a real distinction at all between level and growth rate. to say there is means there some kinds of mechanism that generates a growth rate in health spending and i'm not sure there is. i think a growth in health spending just means a change in the level from one year to the next. so if you go back to what don was talking about lately, these wedges, that what you get, what increases health spending, is a bunch of decisions that are made everyday, and and then they get may begin the next day and the next and the next day. so there's not really a process that you can identify to kind of target the growth rate separately from the level of health spending.

you look at the level of health spending, and address what's in your that you can then kind of not have more of a necessarily. so i'm not sure that it leads us to a productive set of policies to try to separate those two things out. >> actually, i think there are mechanisms, but the point, i think the level in growth, once you've gotten it out inefficiencies and waste, you've done it. then you're back with some city states rate of growth. so yes, to david's point, you can save 1% a year, but for example, i can do that by raising the deductible. but at some point it gets ridiculous. it doesn't serve the purpose of risk-sharing. or i could do it by putting more risk on provided, but once i have a maximum discount on provided, i've done that.

the two colleagues, my two colleagues at cms and i published the piece that is in your book on mechanisms, and we talked about income changes over time, which are certainly common across the developed countries, and this goes partly to joe antos talk. we thought that accounted for 29-43% of the change in growth, and we thought that interacted with technology, again goes to joe's point come at an auction passionate interaction was another 29-49%. the insurance changes mattered less. i do think there's some, and our data, we are looking out across the oecd and the demographic changes mattered just a little bit. so chronic diseases, to go to ken sport, are also increasing i think throughout the developed,

certainly diabetes is increasing throughout. so that i think going forward, that's also going to be driving cost, as he said. but again, i think all of these things are different aspects of the same reality. but i do think there is a mechanism that is driving the growth rates. >> i think dallas had a hand up. >> just a quick follow on on that set of points is, in work that paul has been doing with the database that we now have, that has seven years of data pre and post design change, by a major employer. this goes both to joe's point, that makes sense, and joe antos' point of this is where there's some quotes freedom and it

innovation, the most common change on the private side over the last five years has been moving to far more shifting to an individual, high deductible, hsa, h.r. eight, et cetera. this particular company did all of that. it produced, when one does the analysis and allows the analysis to have all of the new entrance blow in, which based on looking at the literature is the way most of the analysis by insurers and others has been doing it, then you see, not only an initial decrease in cost, but what appears to be a decrease in the rate of cost growth. in this particular case, the second you take out and do the analysis on a closed group basis, so all you're doing is following the individuals that

were with the employer in the plan prior to the change, and then carry them through the first five years, you get a one time shift down similar to the old managed care shift. and then the cost rate actually is slightly higher than it is for the end quote full population. we haven't been able to find other studies that have been making that closed group analysis process in itself, but there may be the appearance of good news out there that isn't quite as good, vis-à-vis what is happening. the second point i think which goes a bit to what ken was talking about, and others on the chronic issue, and i'll flip to an article, fairly thorough piece that was in health affairs

with a much lengthier piece then followed it in the "washington post," on lyme disease. and if you take the state of virginia, when the current governor came in he, for the first time, appointed a governor's task force. the governor's task force came up with recommendations to the governor said we shall enforce the recommendations. the state health department began and a media process of sending out mailings and creating educational requirements for all those licensed to practice in any way within the health system in the state of virginia, and the rate of test positive reported cases of line in the status -- virginia has skyrocketed. as it is also at cdc, the highest rate of reported growth

across 48 states at the moment, as it is becoming through health affairs, popular media, gubernatorial task forces. that is a disease that the infectious disease society treats as an acute disease. it can be easily cured, they say. and for those who think they have a chronic disease, who are in a wheelchair after treatment who still can't chew after treatment, et cetera, these are all deemed to be non-lyme related and non-treatable, those that are told they have chronic fatigue system -- chronic fatigue syndrome, et cetera. so this goes to the dual eligible, one of the fastest rates of increased and granting of social security disability, and with it medicaid coverage is, in fact, lyme disease individuals who, according to

the infectious disease people, don't have lyme disease. but relative to the chronic conditions do. so it's just to underline a number of the comments, both on the treatment issues, on the analysis and diagnosis issues, and to the technology issues of testing the fact that lyme testing, as the article in health affairs pointed out, and elsewhere has been pointed out, is an extraordinarily ineffective, very high rate of false negatives test, and there's a tremendous need for advance in that area. but even with a lousy test, it is suddenly producing new cost that will push the cost growth curve as we move in this area. so the employer side, joe, i agree with you. there has not been a tremendous

movement, if one looks at the magnitude of that system towards significant change. those that are making the shift to high deductible and in essence thinking they found nirvana. when you cut the data just looking at a constant population, nirvana still is a long ways off. but to the point raised by others, a one time decrease of 17% before it starts going up again is not necessarily a bad thing. and then i'll add the final caveat. hsa's has established under federal law, the data is not owned by the employer. and, in fact, in most cases only one of the insurance carriers in structuring their products so that they actually can do an analysis that includes what is

being spent out of the health savings account. and even within because the law allows the employee to move the hsa provider bank, and then there's no reporting back, is the vast majority of the research to date, excludes from analysis what is being spent out of health savings account and treats that spending as not occurring. so the data on that whole area is exceedingly dirty. >> comments coming anybody? >> okay, let's see, i think michael barr is next. >> thanks susan but i'm going to go in a slightly different direction if that's okay. it's been refreshingly sunny that we been enemy about two and half hours on the role of technology, chronic conditions and no one has mentioned the phrase meaningful use, which is nice but i'm about to change the. i've a question for the panel. in full disclosure i'm on health

i.t. policy committee and the four subgroups meeting different ideas for stage three. but i'm curious from the panelists whether they think stage one of the proposed objectives and measures for stage two are moving in the right direction in terms of helping us to improve our chronic conditions and manage cost and whether you think so or not, what would you recommend for stage three? >> total interoperability. until you get that, you can throw out meaningful use and this, that, and the other thing and say that, but until you have the different ehr's speaking to each other and the data being transmitted from the special to the primary care with two different systems, you can measure all you want but it's not going to help us. it will still be inefficient for the practitioner.

>> i guess the comment i would make is, so where is functional assessment in all of this. and again, as a practicing physician i get the valuable of this whole data point. but when you look at the population of both diane and i show data, if you reflect to on melanie's broader comments about her current focus, and to we understand the role of function in both physical impairment and cognitive impairment, you know, you can write prescriptions and stuff and you can detest and stuff into the cows come home, but you can't understand whether you can sort of thread that dataset to the life of a full adult human being, that's a real problem. i see that as being totally missing. >> brad. >> in the spirit of specific recommendations to reduce costs, i'm connecting the dots. i want to follow up on something

bruce has been saying, and that is the importance of functional impairment. and it's not just because, you know, people when they can't function, you know, utilize. it's the multiple chronic conditions plus functional impairment. those just happen to be two of the most powerful predictors we have for mortality. the bottom line really is that if you look at the population, that has more than three chronic illness diagnoses, and functional impairment, you're looking at people who are getting new the end-of-life. where spending is very high. we all know that in medicare, 20% of all medicare dollars goes to patients in the last years of life. 30% of that 28% is in the last month of patients lives, and 80% of that is in the hospital. i thought the articles that were supplied today on really interesting. the advamed is one.

this is the population that we're talking about. as ken mentioned, death panel rhetoric has kind of paralyzed the debate on what to do about these folks. but i just want to suggest that the managed care approach of targeting costs and thereby reducing utilization, there's a word for that. it's rationing, and it cost managed care to be torpedoed across the country, and we saw what happened in one of the graphs we saw today. i would submit to you that targeting costs in order to reduce utilization, and this high cost vulnerable population is exactly the 180 opposite of the way we ought to be going. what we should be doing is looking at the word cloud. hospice, those of us have done hospice for years know that you can be a day away from death and

be very comfortable, very functional bowl, delivered or not, very happy at home, all the words in the word cloud are fulfilled. and we can target those kind of personal preferences in order to retire, reduce utilization because a lot of these folks do not want to go back to the hospital. if you start with personal preference and then reduce costs, that's the right direction. nobody's going to argue with that. except for those who just think personal choice is just a bad word. but out in the real world what one wants should be driving what kind of care they get, and we don't have mechanisms to make that happen. except in a few places where we have trained teams to be in the home and community to move the focus of care out of the hospital for this population, to where it needs to be, or the word cloud is fulfilled. i just want to put in a plug

really -- and by the way, 20 years, i do not think by itself is the answer. because it's viewed by most physicians as an alternative to treatment. so it's either we treat and one weird entry to you and we turned over to palliative care and hospice. that doesn't work. i can attest to that, with decades of frustration. what does work is to train teens to see what people want. and to both treatment and comfort care in a package. we can do that, and we are. i want to put a plug in for sea-tac, coalition of transform advanced care, which is here in d.c., putting in the process and measuring results on exactly what we're talking about. and i think makes me go be great to go into this more and more debt because we do think it is a way forward. >> great. >> i've been talking to students

about decision-making, some other and four, long time. and i would write down on a blackboard utility function, and everything flows. i went with my wife to see a lawyer about redoing our wills, and so i got to thinking about what one would say in advanced directives. it's very hard. i'm in, we know from all sorts of studies that people are bad at complex decisions, which is there that any emotional context. i'd like to think i'm pretty good at that time but just trying to say either morally or in writing to my wife -- orally and in writing him what i would want, there's a vast range of circumstances looking forward, that the simple kind of example we get people about the doctor says, welcome you have an x. percent of chance of survival,

and finally, here's what will happen, what kind of pain and suffering you will have, probably most doctors are not good at giving those probabilities anyway. so while i intend all for bringing in the patient, i'd have to turn in my card as an economist, i think it's actually very, very hard to do this in practice. and then pretend we have made a big advance. now, not think some cases we clearly could, but as one starts to push it and gets close to it, i think it's hard. i'd be interested in what brad has to say about. >> if i could respond, you know, i have to say, joe, i agree completely with what you just said, you know. as a doctor in an doctor and the office and i see you, or talking with attorneys, a one shot

conversation on advance care planning yield very little. i think if there's a secret to this, it's that as people get more and more ill within this period, where none of us, if you're sitting at the table you are not this sick. people are talking about, can't even make it to their doctor's office or church. they are very ill. once you get that sick and move through your illness, if you have a trained team they are helping you understand what the illness is about, and helping you understand what your real options are, one of which, of course, is 911 when you lose your breath at four in the morning. there's others as well. the interesting thing about the word cloud is that the people who are the most ill have the capacity to live just like the words in the cloud, but we teach them to come back to the hospital. we don't teach them to manage themselves, to see what their

options are, and we don't put help for them in their homes. and i think that's why i think what you are saying leads us to the place where it have to better care coordination in the community, and we have models and data showing that works. because you can't advance care planning when you are well. it is too complicated and you are not down the decision tree far enough to know what's going to happen. once you are that sick you do know what happened, and you adapt and that's what decisions over time with trained teams make a difference. >> ken? >> i know i mentioned this in my talk, but i guess just wanted to reiterate that i think we could do three simple things that are not going to solve the problem, but they are going to contribute to to the solution set. and there'll be an expensive so we're not looking at something

that is a big set of expenditures. one is on this prevention side. as i talked about you look at a prediabetic, overweight adults at age 50, they have an 87% chance of having diabetes during their life. if you roll them in the diabetes prevention program i just talked about, lifetime likely to getting diabetes is 62%. so that's a program that we should just roll out nationally. and then leverage medicare, refer patients into it. that's a program we could do for $80 million. less than 10% of the prevention of public health fund next year. so i went to the -- second is that we've got to build up the score nation. into traditional fee for pay. at the same type of care coordination and as we heard they own the chronically ill

population. that's what they are. and so we do know from a whole host of data from the private sector, from randomized trials, functions that improve clinical outcomes and reduce costs. and i went through some of those like transitional care, health coaching, medication therapy management, and so. there are models that we should integrate into pay for service medicare. and a third thing that we could do is pay attention in the definition of the central health benefits for plans offering services in the exchange is about what do we mean by prevention and ordination. we spent a lot of time on the other element find out what it isn't so. we spend no time really thinking through what do we expect things to do in terms of preventive services. i'm not talking a clinical preventive services. i'm really talking about these of versions but and care

coordination. and i think that's a really important discussion to have with states, with health plans because kobe and company amount of transition from patients from medicare to private health plans within the exchanges, and i just think that something that at a state level we need to get on. that obviously in terms of costs, minimal, if any big but those are three things we could do right now i think it would make a real important contribution to reducing health care spent ken, i did want to follow-up on your point about prevention and the diabetes prevention program, because as you know, a large share of the long-term analyses of the program show that not within the fact that many people to lose that five-7% of body weight, a very large share of them get back. there still is a benefit, as you said, in terms of at least delaying progression from prediabetes two diabetes, or causing it to cease in some

people. but it gets to this issue that i think joe newhouse is put back on the table which they turn the people do not operate in the best interest. we are quite aware from the field of behavioral and economics. and do we understand really enough about human behavior to know that these interventions are going to have a lasting effect? >> well, we know the two facts are laid out in terms of the long-term likelihood of getting diabetes for somebody age 50. again, we are sort of paralyzed here with not doing anything without having years of randomized trial. gosh, it's a good thing the private sector doesn't work that way but medicare does. there is a 10 year follow-up, and we know in the 10 year follow-up that yes, there is some weight regain after year three or four, but that just means that we should focus on what can we do in your three or four to reinforce it.

because that's the first point. the second point, i say so what? is still is a 34% committed reduction in the instance of diabetes within a ten-year time the. so compared to doing nothing, we have 34% less. all right. >> one of the elements on the table is adopted diabetes prevention program national. you said $80 million a year? >> we are not used to talk in about games. 80 million. i could ask for more. sound attractive if it costs more i guess. but 80 million, yeah. >> jim? >> i'd like to go back to doctor stewart's comment about end-of-life issues and i think one of the things in teaching residents that we forget to do is were teaching them the technology so they start using the technology. and what we don't teach them is

just because we can use something, should we do something, that thought process. it's far easier to provide something in a setting of end-of-life, or something like that, without thinking than not doing it. one, you feel better because you are trying come even if it is a hopeless case. so i think this also gets to the point we mentioned about patient centered medical home, and some of the stock about that, is we need to look at understanding the use of the technology both by the primary care doc and the specialist. and make sure there is a coordination in use of that technology, both in the setting of the first workup of the disease, and also at the end-of-life. when a lot of technology is used that is really not going to aid or help the patient in the diagnosis, treatment or even the comfort. so i think one thing we haven't

looked for discuss is getting back into the teaching realm of the medical schools and the residencies, in understanding, giving them to understand the use of technology better. >> and to get them to work as teams. and, as i look, any academic medical center where the school of public health, medical, nursing school, school of social work, they'll all see us impatient at some point during the course of that patient's treatment. but there isn't a structure that really gets them to work together to think about how do we work collectively as he came to keep that patient data from getting the disease are healthy spent i would just add, there was an editorial i think in "the new york times" a couple months ago that internal medicine has to get more like pediatrics. my training is pediatric cardiology. and believe me we have a social former, social worker, our colleges, how to do the bottles

but they didn't leave the hospital until parents could give the med, could give it up early, even if it cost the hospital an extra day and wasn't reimbursed. the patient didn't go home until the point was made. >> bruce spent maybe to build on that. you know, i think about my limited public health training when i was in medical school. but it actually had a framework that said there were three levels of prevention. primary prevention, and somehow most of the discussions i'm involved in seem to focus on prevention and a very primary kind of way which is all about preventing people from getting it. care coordination is all about those other two kinds of prevention for people who are sick and possibly treatable, and for people who are sick and treatable but not terrible. and so i think we need to get back to this notion that a really good care coordination plan is actually a form of prevention but it is a public health responsibility. sorry to sound so energized but it is missing from these

discussions. at the end of the day i will go back to the question which is what our, what is the problem we're trying to solve your? at the end of the day, we developed a tradition in late 20th century american medicine of introducing a pill or a piece of equipment in place of a good discussion. any situation when the outcome is functionally driven, not medically driven, you're not going to fix the fact is presented substantial stroke and is now in the pelagic. you have to focus on the quality of life and, frankly, no, i agree it's a medical school issue. it's a issue because it is a framework for care coordination, understand what the person's medical and personal goals are. we continually substitute expensive potentially very risky therapies in place of a thoughtful and evolving care plan. when you are seriously ill or have substantial function limitations, it's not a fixed point. it's like a mosaic that involves.

evolves. care to change them around when the image changes. so there's a larger discussion about how technology and part of why i think the notion, melanie, as you guide into the work you're doing, a care plan that is revisited over and over and over again. my one fear about the fee-for-service medicare peace is that someone will get a piece of code that says once a year you get a visit and then there's some follow-up. it won't work. it just won't. so there's kind of intensity and his intervention that is important but it goes back to the fundamentals of public health. i'm off the soapbox. >> could add to that just very quickly? in the interest of actionable steps, there's been a lot of talk about what's effective care, how do we change medical health, how do we teach residents. our experience i think, a big 24 hour hospital system, is the way to change medical college is to change the structure of how the care is provided.

and i have to say as a doctor that i don't think doctors are the answer. you know, there aren't enough of us to go around with a grade way that is about annett davis. the teamwork that we need our teams of other professionals that can work with us to extend our care to people who need. the kind of people bruce's talk about. and i think the our models out there that provide that kind of care coordination if we have data that shows it works. that simple change in the structure of how care is provided is read in geneva system in that way would really equip us to do a lot of things we're talking about today. and change medical culture in the process. doctors want to be offloaded for caring for these people. can't make into their offices anyway. they are too ill stick there are some more cards a. let's go around the room this way. david nexon. >> follow-up on last couple of comments to question for ken or felony or anybody else.

on the issue of care coordination, teen delivery care, it doesn't, you know, i think the common wisdom that is this is really an important way to get at this population. at the same time it does seem to be a simple as adding on a paid -- a structural change and a culture change for a lot of caregivers. i wonder how we go about doing that in a program like medicare or medicaid, for that matter? >> you're right. it's not a coding change. i still think about the way north carolina and vermont have thought about this in terms of building health teams that work with primary care practices. and away i think you could do it in the medicare program, and i would do it in conjunction with these changes is basically that you would have to contract out, with different entities and different plan service areas to have teams available to work

with medicare patients. i would start off with him being voluntary. primary care practices don't have to use them, but our expense and looking at them in vermont is they do because i think brad's point is that they are a natural extension of the office. they engage in work with the patient. they help them make understand the care plan. a care plan is executed they have questions about the care plan, they know where to go to the our nurses, practitioners, pharmacists that really doing all the blocking and tackling and execution of the plants. they are not physician lead. they are nurse led pics i think you could very easily have medicare bill that these teams and have them available for others to use. if medicaid and state wants to, that would be fun. on a stage doing his. there's a section, 27 '03 in the affordable care act that gives states and enhance 90% match to put these teams into place for two years.

site thinking, nation, i know they're doing this am that would be a way to start building the capacity into the program. you would expect them to do some of the functions as talk about. you would expect them to do the functional assessment. expect them to do some of the social function. transitional care coaching, work with them on health literacy issues. so we have experience in vermont, they do this with medicare patients. in fact, the teams are used to managing all the patients in the provider province. so the challenge we have is that like any type of care coordination program, it requires an initial investment, right? so unless we're going to invest in this, we can't get any of the health care benefits and you can't get any of come any of the savings. so i would hope that through a combination, we could start this

is going. we've been working with states and encourage them through section 2703 to build out the health teams through the medicaid program. and perhaps if you build some broad expectation in these changes about the types of functions that we hoped of health plans provide and compete on, that would be a way to start moving more quickly down the field. i know that if we don't go that direction, build some type of evidence-based care coordination and medicare, you know, the debate about how to save money and the medicare program will be the same one we've had for 30 years. it's going to be cut provider payments, increase age of eligibility. it's the same old same old. and is not going to really get at any of these fundamental cost drivers we have been talking about. >> susan, could i just a quick comment about building anything into medicare? i think medicare is entire history proves conclusively that you really can't build common

sense into medicare. what you can do is provide incentives for health plans to use common sense. but it's only been 45 years so far. >> we're going to keep working our way this year and we'll come back around. carmella, we'll catch you up next but i promise you both, forgive me, but you're so far away i cannot even read name cards down at that in. >> not a problem. i'm a medical doctor with wellpoint. i appreciate this opportunity to speak briefly. my day job is in a redesigned across our 14 blue plans, so we cover one in nine america's across total blue, almost 100 million life. that are a number of different levels that we're using to change sort of the fee-for-service reversing because we've got to change the system that people are going to care in. and all the things discuss, patient preference, very

important. supporting physicians with data, i.t. has got hope that with and rockabilly. that one of the levers, and our multiple levers were going to need to create is one that i would like to call attention to the touch of both chronic care and technology. it's something that is across all blue plans, was 100 million lives from a data perspective. the national cost comparison tool looks at over 200 commoditize type of inches of health care services, colonoscopy, joe commuter with your cataract example, it shows that iraq, total cost from door-to-door, includes everything that is associated, protein facility, and ossetia, and it's very informative. colonoscopy, for example, and heaven forbid if you need an imaging this afternoon, all imaging for sciatica is on there as well so you can be smart about where you spend your health care dollars. this tool is really important because it because we think about moving for the amount of information that flows to help you make better informed choices is coming in here. so appreciate the moment. >> great, think you.

so we will keep moving this way. >> kirsten sloan with a national partnership for women and families. i just wanted to touch on the care coordination that both bruce and brad referenced, because i think this really is a critical actionable step but i would also caution that part of that care coordination team really has to embrace the patient at one of the things we consistently see is care plans written for the patient, care coordination done for the patient, but when it doesn't include the patient, when the isn't an understanding of where the patient is coming from or what they are capable of doing, oftentimes we fail. and so it isn't just to be nice to the patient, but this actually is a key to the success of a care plan or a care coordination effort that we're using shared decision-making tools, that we are using things self-management programs which consumers and patients are actually asking for. but unless we engage them in the family caregivers as well, i

think we'll miss, and susan to chart actually show this, that people don't adhere to the kinds of treatment, regiments that they are recommended. and instead would end up costing the system more. so if we can prevent hospitalizations, if we can prevent re- admission, because we've included the patient and caregiver in the design of a care plan or the care management, i think that's a good actionable step. >> henry clay pool from hhs. actually with the administration for community listings. under secretary sebelius, just recently formed at the department. and a couple of points. the point about really beginning a dialogue with an individual about what the future is going to be like when they are living with certain condition or towards the end of their life, there's a whole population of individuals living in the kennedy today with functional

need. and i would suggest that that's a great place to begin to really start to we shape the dialogue that occurs between the individual and the clinician or the patient. if we don't begin to pay greater attention to those individuals that actually have the real-life experience, living in their communities, and involve them in shaping how the services and supports, and the treatments, that they need are delivered to them, i think we will continue to run up against the cost issues that we see today. just listening to the dialogue, people are relatively uncomfortable with the idea of what the future might hold if they did incur a functional need. again, there's a group of people living with it day to day. we've seen modest advances in the medicaid program made where individuals are empowered to take some, a bit more involved

in directing some of the services. there are certainly limits to which these individuals should be engaged in directing their health care services, but they are really at a critical juncture in terms of leading the change. another group that should be involved, and i think back to ken's point, it's really at relatively modest investment because the committee based infrastructure that's out there to serve this population is really underdeveloped. and until we make some modest investments in this service delivery system, our medical system will just continue to strain to meet their needs. there won't be a partner in the committee based setting to make an appropriate handoff to when we want to just discharge someone from the hospital and make sure that they get the services and the care they need. so that they don't end up back in the hospital. unfortunately we have learned this the limitation of the

affordable care act, with care transitions grant. we're still making grants that hhs, but we really know their underdeveloped. and so for policymakers in the future, looking at making investments in something like what the secretary has created in the administration for community living really might be a sensible alternative to trying to continue to do this through a rigidly structured medical program that has involved the political dynamic has been pretty thoroughly discussed here today. >> henrique. >> thanks. henrique martinez, i'm the director of the foundation state coverage initiatives program and also ran for the state quality improvement institute for several years, commonwealth fund funded when worked with a stay some quality improvement reform, and just to give you a few more examples of what states are

doing out there, try to talk about vermont and i will add a point or two to the. but under our institute, states want to focus on how to deal with costs in the quality improvement but it is really how do we deal with costs in. if you think medicare has problems cutting reimbursement and cutting services, that's what medicaid does at at this sort of that that out at this point prepared to the end of the rope with it so they're turning to another way to do this care coordination. it's a huge thing. payment reform, a lot of states out there are doing primary care medical home, trying to even get the acos in terms of medicaid. colorado is doing that, even new jersey is doing that. oregon, which i'll give you a more detailed, a little bit of a vision at this point, but they are really thinking broadly. consumer engagement is a huge piece of that, not on financial incentives but also the

education peace. susan was talking about. health literacy was a big piece, as well as sort of the wellness program. how do you do that ahead of time, how do you stop the cost from even occurring. health information technology was a huge underpinning aspect to this, bringing all this sort of how the interoperability aspects to this is critical. and then the metrics, accountability. that was sort of the overall package of work we've done in a number of these states. vermont, as ken relate up, was a visionary aspect to what they did. that was all built around the medical inspectors who can figure out how to get to a next layout with specialists and hospitals, but they also come health information technology that underpins the whole thing, registries, interoperable, electronic health records and accountability matrix, and for outcomes. the other, just one last point,

what oregon is trying to do with their coordinated care organizations is still a bit of vision, but they have gotten cms waiver to implement this. it's a huge undertaking. it's going to be medicaid, state employees, high-risk pool and hoping to bring exchange is will eventually when they get up and run. it's really just sort of integrate and coordinate benefits and services with local kimberly to health and resource allocation, standards for safe and effective care, and the global budget that is sustainable growth. they have a website that explains all the. i would recommend people look at chordata care organizations like oregon is putting together. that's if you examples of real work on the ground. >> thank you. diane. >> i just want to go back a little bit to where brad was about people ending up in the hospital in the last year of life and in the last month. and sometimes we learn from

research and sometimes we learn from personal experience, and we've talked a lot about the coronation of care which is basically in the community. but i think there's a different situation that we also ought to focus on which is that my mum had a really good primary care team and coordination when she was in the community, and then she ended up in a hospital to be treated for dehydration and then she ended up in the hospital longer and longer and hospice to go. i couldn't get anyone to answer any of my questions, and hospice can turning over and turning over, and i think that final i just got are discharged and brought her back home. but i think that we can talk a lot about coordination of care when they're not in the hospital, but we need to also be looking at the whole trend in the hospital towards hospice and what that means for the ability for the care to be managed. >> thank you. susan. >> yes. i also wanted to mention around this interprofessional

collaboration which is the foundation of care coordination and the infrastructure that was mentioned. the are some things that are happening, some of this can be pushed from the public side and some of it is being pushed in the private sector so on the private sector foundations like the commonwealth fund, for example, that is done work on, trying to get people trained in the. i think is really important people who are already out there, not just new which is really very critical to there's the robert wood foundation which determines amount of work. at aarp were working with them. that has a high high priority on interprofessional collaboration. we have 49 states with action coalition, many of which are making this a high priority for the state across different disciplines. it's very, very challenging. we know that. there's been efforts before to do this, like you also have a person now saying, tying funding

for education, all professions to interprofessional collaboration. so there's lots of different things that i think our efforts to place that i think we should all be trying because it's got to be done from the ground up and we have to change the culture among the existing professionals. >> thank you. >> okay. one of the major topics of today is technology, but i will refer to the discussion about the process of information. i think we all sort of belief, there's possibilities for improvement of innovation and technology. but a lot of the literature, a system both private and public dominated by fee-for-service, that the incentives are more sort of cost increasing innovation as opposed to cost decreasing or value seeking innovation. so my question to the panel,

sort of is this distinction in order? and as long as we stay in medicare and and the private sector, a system dominated by fee-for-service, how do you get this sort of change and incentives for innovation into the system? >> joe? >> obviously incentives are important. i think there's an issue about, from the public financing, or even the private financing point of view about how who gets those savings, the city, there's innovation dashing vis-à-vis, there's innovation. there has to be some incentives for the provider.

i'm somewhat concerned about increased market power provided, that they may make most if not all the incentives. or savings i should say. but that's speculative. so yes, i mean, i think as risk it gets pushed down towards providers, and i believe that some, that should occur to some degree. that would increase incentives for providers to demand cost-saving innovation. but then who gets the savings? >> okay. brad and then carmelo, and then we will wrap up. >> a couple of points. around jericho nation, we kind of talk about it, but we sort of assume that we're talking about court meeting care across space, geographically across settings. to diane's point.

care coordination in my experience it doesn't work and lets you wrap together what happens in the hospital, what happens in the medical group, physician office and what happens at home, and community. it is possible, there are models out there, that bring all of those together. that's the only way to deal with hospitals who don't want people to come back again and again. they just have to deal with them when it happens. so care coordination across space is critical, and of a lesson is that it doesn't work. by care coordination across the time is also important, meaning, this goes back to joe newhouse his point, when you are well, why wouldn't you want to recover and do everything you can to do that? when you are super ill, your preference is changed a lot. and tracking those preferences, not getting them, getting them into the ehr and following them

is court meeting care across time. and both of those have to happen. and again there are models that do that. now, the second point is financing. again, back to joe, shared risk, shared savings probably is where we're going to end up. we have to have providers sharing risk with payers and with medicare. but you can't just jump over to get there because we're in the fee-for-service world and it doesn't commute can't just go from here to there. we are paying $20 million a year ourselves to put these teams in place in order to save medicare $2000 per month per patient. we are willing to make that investment because we know we will get at some point shared savings, and we're talking with cm and my about doing that. but the little providers out there can't possibly do that,

and nobody, everyone is going to be, and aco. so our proposal would be use of these across space and time care coordination teams to allow independent providers, hospitals, medical groups, home care agencies to become virtual acos. and i make that as a specific actual proposal, and then create internal financing tell people over the bridge to shared, risked shared savings to that's exactly what cms wants to do. that's got to be a way to pay for quality on the way so yes, you get paid for now, but you can't game the system. you have to make outcomes in order to get reimbursed. so that's going to take a lot of talking but i think there is a concrete way. >> carmella, we will give you the last word. >> so, i'd go back to the

proposal ken, the plea ken but on the table about prevention and diabetic care, and a fortune i have to agree with joe antos. medicare is just 800-pound gorilla that is a flexible and doesn't move like that, and they try to create programs one size fits all. this is not about one size fits all. i mean, i think as we look at what's going on in the private sector, we have a lot of physicians in this country that are in one or two doctor offices. they'll have very different needs and have different infrastructure that they need to build than physicians better in groups are part of the integrated system. and every time we have this conversation we sort of forget about them. and i very much worry about them, because they need certain support if you're not going, if they will survive in this new and vibrant. and i also think we have to think of primary care very different event specialty care. i found it really interesting

that this was a meeting about technology, but we focus a lot about primary care today. i'm not concerned with primary care and technology. the data we look at shows that technology is used and overused and misused more by specialists than they are by primary care it and so i think we need different solutions for primary care than what we do for specialty care. specialty care is very much oriented to procedures and technologies. and i go back to something jim said. we do a good job of teaching physicians in training, how to use technology. we don't teach them when not to use technology. we don't teach them that it's okay to say no. and that's a real challenge, particularly for physician who has spent over a decade learning a specialty and they want to get out there and they want to practice medicine. those to me are some of the problems that we have to grapple with. i think all the discussion on

primary care today, care coordination, care transition of across the continuum of health care is actually important, but when i think of technology my radar goes to us specialist. >> i'm going to rebut you here, carmelo. 30% of the echoes we read, i read were ordered by the primary care doc. they had zero yield. none were needed. and i'll refer you to the pilot program we did with nuclear studies, 10 settings. yes, specialties order more tests because we have, that's part and parcel of the stethoscope, as joe mentioned it at the same time if you look at the inappropriate raid of the specialist versus the inappropriate ordering rate other primary care doc, which accounts for about 30% of the tests been ordered, it's 50-60%

for the primary care doc, and they don't need a test at all. they are trying to figure out what's going on with the patient and order the test because they don't know what's going on with the patient. the specialist orders the test in a patient already has the disease to make a decision, and their inappropriate raid is doing it too often. it isn't doing and someone who has a steady. so it's two different aspects of the testing. and again, you can get about a 30% reduction on a needy, completely unneeded testing by just having the primary care docs call the specialist and say you don't, what's wrong with this patient what do i need to do this? that's what our focus tool does. the tool sits on the electronic record and looks and says is this an appropriate study or not. ..