>> i hit the bottom on my refinance. >> i at this late at. he will start with labour market questions. so what about the shift to a part-time employment? how does that affect your outlook? >> that is dangerous. where you think the labour participation rate will bottom out. is it possible for elaborate participation to get down to the 1950's level, 60 percent and the like? some suggest that there is paradigm shift in the nature of work and the resulting decline of the demand for human workers. it is kind of like i robotic it.

but does that have an impact? a relationship between technology, what i think i am hearing and the labor markets. and is there any data projections that the effect of the baby boomer retirement to the exact amount, what will be the effect. >> all right. to let me start with the part-time question. their recent data have shown an increase, the share of job provisions which have been in part-time employment. that is out there. the a exact cause of that is not clear in no way that the data are collected. a lot of discussion of it being a result of the rules for the health care implementation.

this share of the employees who are full-time. i believe in incentives. i think if you put in place a structural components to their cost structure which is triggered they will react to that. and i mean, i learned about marginal tax rates from salomon richter when i was in high school. he worked at the local gas station. he would get in his 40 hours and then they would ask him. he is a really hard worker. at that time march on tax rates on overtime pay was somewhere in the 50 to 60% range. he called the people's tax cut. [laughter] and if it was not going to be in cash, also really good fisherman

. involve fishing. businesses are rational, and some of them have spoken publicly about the fact that they will alter their employment practices. an important question than, if people want to work full-time with the only work part time, will they pick up another part-time job? the answer is probably yes. the question is, will be combined benefits of those two part-time jobs he pull the financial strike that one full-time job which its benefits would be. that we do not know the answer to, but i am sort of doubtful. that is just an opinion. what about the bummers and their retirement? the one major u.s. seen a pickup in labor force participation is the over 55 group. i'm all for that and it is good for themy.

that generates higher productivity gain. replacing them will be a costly exercise. but the reason for the increase in that labor force participation rate is undoubtedly related to the loss of equity wealth in their homes with them having to go into retirement, they want said rebuild. i don't see that as a trigger for increased consumption. i see that as a trigger for increased savings. so to that view that folks see that pushing employment forward anti-nafta consumption, i am not in agreement with that. they will not be increasing the pace of consumption. they will be increasing the savings rate. that is another reason we are more conservative on the consumer spending side. the technology level of employment, if you alter the

relative costs of labor to capital you well in send firms to shift one direction or the other. if you decrease the cost of labor relative to capital there will be a shift to labor. the employment of technology and people. that should be an important consideration when we are altering the rules of employment. the health care bill is one of the things that will impact that today we look at this and has fallen, and part of that is a shift in the structure of the tax code and the shift in the benefits compensation. so if those were kept in balance

the improvement in technology will drive productivity gains, productivity gains are what drives real income gains. there should be a healthy positive relationship between the two of them. >> so i did get a question of health care reform, and you kind of just answered. in case you have other thoughts. >> other thoughts on health care reform? >> this is completely a personal -- this is completely a personal point of view. for me the most important thing that we could do as a society to improve or reduce there share of gdp that goes to health care is to encourage people to be of the . the health care bill did not have any of those incentives ended. incentives, carrots and sticks

for people to get in shape, reduce obesity, make healthier choices in food and in their recreational activity, that's got to me, would be the place that we could make the biggest changes in in reducing the cost of health care in the economy. >> personal check is for everyone. all right. a lot of questions on the real-estate market. so can you comment on the economic impact that fracking is having on our economy. competitive advantage for the u.s. an uptick in local manufacturing as of the domestic energy. >> i had a brother who lives in bismarck and he recently came to us was in d.c. for wedding.

came to d.c. he said that the plane was noisy from bismarck said minneapolis, and it was all southern drawls. it was quite from minneapolis to d.c. so this was the oil field workers having migrated to north dakota for the development of the balkan shale. in the 2000 census, so i see that. only one of tuesday's that did not increase in population. i am trying to think about that is a bad thing. [laughter] give you a little sense of what i think about all of the southern drawls. on the other hands, both of the daughters are grown and out of the house and that of the state. he feels okay with that.

the influx of labor that developed that shale deposit is actually causing some really interesting questions. one of them, there is a difference between the development of the oral source in the extraction. so we get requests for financing to build apartment buildings. how long-lasting will be the labor that is used in the development of the fracking process. so when you make a longterm investment in an apartment building. maybe there are only five years. and an extraction may have a different pace of employment. in either case this is going to add to the employment side of the economy. it is just a little different depending on whether you're talking about development verses extraction. that is the first pause. then if you think about that expansion and that somewhere in

the 2020 range if things go well will be energy independent. a lot of indications. geopolitically very important implications which could go on for quite some time and could have large national implications in that way. it is also the case that it will lower the cost of energy inputs for households. so as that share of either their automobile was their home heating, those kind of costs fall, that frees up resources for consumption in other areas. if the reduction in transportation costs becomes the energy piece, often advantages to our manufacturing folks that can lower the prices of produced goods because it is cheaper to get them to market if they're is a component of the goods being produced which are petrochemical related then that reduction in production costs will provide an

advantage in terms of relative pricing to others around the globe will might produce those things giving as an advantage in global pricing, and it is likely to reduce and lead to an increase in manufacturing. there is relationship between house of consumption patterns because of their energy costs, between the relative value of manufacturing here versus someone else and the price advantages which fees back to our consumers but also makes us globally more competitive. so this is a real positive story potentially. it will take some time to get all of that developed. and obviously taking care of the environmental factors of that as well will also be an important consideration. but it managed well it is a very positive tailwind for the economy going forward. >> we taxed on this earlier. i don't think it came back.

historically high level of college loans impacting consumer spending going forward. >> we are concerned about the fact that college debt is, i think, four times higher than its previous peak. part of that is because the duration of both the crisis and slows subsequent economic growth has made job prospects for college graduates a lot tougher, a lot less available than some previous cohorts which has meant they extended there time on wednesday barred to add to their human capital. really the most important factor forward as income growth. if we generate jobs and real income rose and a reasonable pace then there are likely to be a will to handle that, although it will take a little longer. it will probably delay certain other forms of consumption by buying a house may delay the time.

but if ultimately we get a stronger path to economic growth there will be a little at. one of the things that is changed and the more news space is that we have put in place to regulation a fixed ratio between debt and income in the underwriting process. set to the extent that these households command with a higher level of debt relative to income, it will keep him out of the house a space longer until they get that ratio back in balance. really the big issue is real income growth, and this expansion has been the slowest pace of income growth of any expansion since world war two. >> is there any anticipated effect from eminent domain actions like richmond, california, the underwater market, underwater mortgages coming any real concern in the organization around that?

>> our regulator has made a public statements in opposition to that particular theory and its application of the more space. we have filed a formal document in support of that, actually undermine name. you can go and be provided metrics from our perspective, but it is an ongoing legal case. while we are not -- we have not put forward this to ourselves, we are an investor on behalf of the testes on behalf. i really cannot comment much on that. >> okay. >> that's it on to the real-estate market than. to you think that home prices in the next ten to 20 years, any chance they will rise the same

way they did the last in a jaunty years, is that a once-in-a-lifetime opportunity? >> that was a bubble. hopefully what is being put in place, as series of changes which will prevent the emergence but the bubble and the number of sources. it was not just the mortgage space. i commented earlier that one of the positives for the demographics. the global population is aging rapidly in important ways. the u.s., canada, the u.k., and australia and new zealand are really the only western developed nations to have reasonable expectations of labor force growth through 2015. all of western europe is currently were well within the you're to be actually seeing declining population.

russia is rapidly declining, and japan is a long-term demographic disaster. the birthrate for replacement that is the whole population constant is just over two. japan is at 13 in they don't allow immigration. a lot of people don't realize that china, because of their once out policy actually has a rapidly aging population and very little social safety net work. within the investment advisory world it is always a piece of advice that as you age you should shifts toward fixed-income instruments in retirement. if you think about this rapidly aging population the demand for fixed income as germans was growing at the same time as gl my chair policy was very easy and the investors in

fixed-income chief of -- securities specifically you requested are more security related investments would take a aaa rating by rating agency as private is a is -- evidence that this was a safe investment. that was a global phenomenon. so the u.s. created essentially a mortgage machine says that if there was an appetite for the estimate on the demand side it would be reproduced. it is a combination of multiple factors that led to this bubble expansion in credit and clearly cresson is received -- ease the drought. as you heard, i said two things. one is adjustable rate mortgages. that was a problem. and i also said there is going to be a fixed relationship

between debt and then come for households to qualify. there are changes that have been put in place regulatory easing tensions are to hold standards at a higher level and truncate those easier and a ray criteria which i contributed to the crisis. >> so we forget. not as directly, but we don't really know what will happen. >> let me make one related set of comments. if interest rates are rising because the economy is expanding and real incomes are growing and this takes place over time, then the rise in interest rates and the monthly payment from borrowing the same amount of

money is offset by their growth in household real income and has no impact on the pace of housing if interest rates are rising because inflationary expectations are rising, then households tend to view housing as an intermediate term inflation hedge, and they will continue to participate in the housing market. there is essentially no impact. if interest rates are rising because the fed has decided to get ahead of rising inflation expectations and therefore slowing the economy, employment growth slows, income growth slows and then home sales slowed. but none of those impact prices. one of the things about housing is that households have a nominal impact in their decision making from the asymmetry of tax

if you take that 250 or $500,000 of capital gains, there is no tax consequence. if you suffer $50,000 of loss you cannot deduct that. housing is treated asymmetrically with regard to taxes. therefore, house prices and a sticking dow is it -- its not what people think it is. >> a couple of questions deregulation in the mortgage market. so how big an impact of the ability of three payrolls data on housing into it does a 14 -- in the cfe be qualified mortgage to be effective. how does that factor into your forecast? >> is certainly is contributor

to our more conservative forecasts and some of the consensus forecasts because it does constrain the ability of lenders to ease credit criteria to some degree. we had a while back i observed a lot of public officials making statements about underwriting criteria being too tight, so i suggested if there where to mail married economists walking down the street and one as the other, how was your wife? what is the proper response? compared to what? [laughter] again, warning him about economist cocktail parties. the reason i said is a win we talked to some of these officials and said, when you say underwriting criteria are too tight, what is your comparative? it implies you are comparing it to something. so what we did was taken out of

our portfolio data from different time frames in show that there is a relationship between the business cycle and the credit cycle that the companies that. and so if you pledge six floors of underwriting criteria, what you might do is change the relationship between housing and the macro economy depending upon how households adjust to those new fix floors. so, for example, have typically, as an economic expansion goes up , underwriting criteria have eased in the past but now are not allowed to. suddenly they have multiple executions in different credit products to my credit cards, auto loans, those kinds of things. it is possible to shift spending to other spaces a relative to

housing. you can see a shift in the behavior of housing relative to other credit products. alternatively households can then adjust to that by bringing more equity to the table. we don't actually know. this is kind of an experiment that we have run. there is not really history, but we believe that at least in the near term underwriting criteria will be more conservative as a result and therefore our production forecasts are lower than some others. >> a lot of good questions here, we're going to kind of have to keep going. the one question here, search and real-estate markets have really picked up but prices. i think historically had a conversation here around out there really is not one market. there are a lot of different markets. is there anything interesting from your perspective in terms of the possibility of other baubles, many levels, other local markets that you want to make a comment on? >> one of my keepsakes from the

house price bubble, i was in a meeting with the secretary of commerce. he turned to me and said, are we in the house press bubble? i said, well, mr. secretary, i am in the thanh ho camp of house price bubbles, a tiny bubbles. and it turned out to be a little bigger. but it turns out there was another person in the room that lived next door to dine hose sign in minneapolis. he got me an autographed copy of his greatest hits. so that is one of my keepsakes. not the you care. [laughter] in the short -- chart that i share the house price and its relationship to supply, and made a comment that our belief is that the bulk of the increase in house prices today has been a function of supply restrictions.

so if you want to know where their risks or at least one place where we think there are some risks, it is in those markets which have been heavily influenced by institutional buyer bulk purchases. those buyers, if they are a hedge fund, for example, the business model is not a buy and hold for 30 years housing model. and so if there were large group of them that had been dominating a particular market and they suddenly taints the point of view on capital gains in cash flow from that investment and dumped properties back out to the market in large blocks applied, you could see a reversal. that is one potential risk. of course with rising rates that changes absolute and relative yields in the investment strategy. you may well see that. we think it is unlikely that that -- they have not bought in

a property in reality to be broad based, to drive down house prices. in some markets that may have an impact. it is also a question of those same markets, whether organic demand will pick up enough to offset that change. people are uncertain about the huge share purchases that are being cast. we don't really know as much as we would like to. >> i have -- i guess we are kind of in overtime but i don't care because i'm having fun. have a series of questions around the future of fannie mae, gst and the like. i know restored to you have not had a lot to say, will we have legislation that is drafted. i will leave it to you to comment in that area as you see fit. >> i have been drinking a lot of water, so i am relying on

natural forces to bring this to an end. [laughter] well, obviously one of the answer bees in the marketplace today is what happens to fannie mae and freddie mac. i cannot remember exactly. i was introduced as the a distinguished economist from fannie mae. that is not the kind of in dan envisioning. look. absolutely, the quarter warmer bill is in our view the first sustained bipartisan attempts to lay out a legislative structure for a change in market structure that would replace the gst model. that is a first phase, but it is bipartisan, so it is getting some serious discussion. the things -- there are a series of questions that any

legislation will have to respond to before it takes final state -- stage. first thing we think that you have to ask is, should these exceeding market structure contained the elements which will support a 30-year fixed-rate level payment self energizing repayable mortgage. all of those elements are part of what most of you probably have been your mortgage. it is a level payment, self amortizing, repayable, and the interest rate is fixed going forward. so if that must be something that is provided, at least a significant portion, it requires certain structures. a structure that it requires is the element of a bond market, tea ba, to be announced. that is the mechanism that allows a lender to sell to an investor a commitment to deliver

to them in the future mortgages in a certain amount with certain interest rates. that allows that lender to go back and lock that interest-rate to the consumer 60 days before they close the loan or 90 days. that is a structure that is required in order to support that 30-year fixed-rate mortgage. you have to think about, of the elements of that structure. after you have thought about the element of that structure, think about how well capitalized that has to be. that will imply something about who is going to on the elements of that structure. obviously the fact that fannie and freddie mac were taken into conservatorship means there were undercapitalized. capital across the entire financial's has been increased, and that is likely to be the case for the capitalization of the subsequent structures and secondary market.

that implies higher cost in some -- to consumers. then as we saw in the crisis, ultimately the government and taxpayers became the lender of last resort. so the question is do you care if it is remote from the taxpayer? and then if it is going to be remote from the taxpayer, should the government have an explicit role. you have to decide how you put that in place.

saying we would like to see a motion on this to get to get fixed. >> a couple of quickies. do you believe the omb deficit of 3.5 percent of deficit gap is reasonable? you know, is that -- >> well, omb -- that's their short term. they also see the deficit gap rising going forward from the time period. we would agree with that. the big question out there which no one is addressing is entitlement. what is the problem here. don't you share data? are there political [laughter]

please discussion. i thought it was funny. >> talk among yourself. [laughter] well, that's -- in the words of mark twain, prediction is a very difficult art especially with respect to the future. [laughter] with larry summers no longer contention will janet yellen would be picked? what are your chances? [laughter] >> zero would be the latter. it's interesting that's become a political discussion. you would to say january set kind of lating current member, but the administration could have sanctioned that if they wanted to. we'll see. >> in terms of percentage, we're going to -- this is about you. in term of percentages how

confident are you when you're forecasting one year out, two years out, three years out. we want to know reliable the data we're getting. >> right. right. i have teaching statistics while i was working on my ph.d. i had a, you know, student that came in. he was a smart young man. he said he was frustrated with having to take a class in stakes because of it uncertain. he was an accounting major because he liked certainty. i asked him to bring in a ten q we taunted book versus market value and things like that. i'm not sure he may have gone in to medicine or something. [laughter] i -- my forecast, i act on my own forecast. >> the future is uncertain. thank you. >> all right. please join me in a round of

applause. [applause] coming up on c-span2. displncht on the next washington garble a look at bipartisanshipship in congress. bipartisanship in congress.

c-span student cam video competition is underway. it's taupe all middle and high school student. we're doubling the number of winner. credit a five to seven minute documentary on the most important issue you think congress should consider. show varying point of view, and due by january 0th, 2014. need more information? visit student cam.org. defense secretary and joint chief chairman laid a wreath today to honor it was placed at the u.s. navy memorial. [silence]

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possibly ease the pain of the rampage and certainly the deaths involving a dozen human human beings who were killed yesterday at the naval yard. i hope it's some small comfort that this city, this institution, the united states senate mourns alongside them. to my knowledge there's no explanation for the violence that occurred yesterday. i thoughts are with those who are suffering as a result of as loss of their loved ones, and also those people who are recovering from the wound. some are very serious. i wish them a speedy recovery. mr. president, we have about 16,000 military and civilian

employees who work in the naval yard complex. friend, family members, were affected by the tragedy. only a few day ago and the officer on the occasion also when we as members of congress mark the anniversary of september 11th, 2001, during a ceremony on the step of the capitol. we had a moment of silence here in the senate. the shootings are the worst loss of life in the capitol region since the september 11th attacks. centered on the pentagon as far as in this area. the past week, -- yesterday's terrible violence are a reminder that life is federal government l and precious. a reminder of the debt we owe to those who protect our freedom and safety as they serve in the military or first responder.

sergeant arm responsible for our safety was certainlien the job yesterday. he's a dead -- dedicated police officer. that's his goal. i refer to him as the chief. he's been chief before he took responsibility as sergeant of the senate. hey been a street officer far long time. he scrolled done other things. he has a law degree, he's a well-educate man. his responsibility is to take care of the senate and he does it very well. i appreciate very, very much. i speak for the entire senate of those dead dedicated police, fire, rescue who put their live on the line to prevent more loss of a life on monday. if particular, with mr.

president, they owe a debt of gratitude to a canine offer. a 24-year veteran. who was hurt badly in the shoots. i wish him a full recovery. and thank him for his selflessness. >> all of us are thinking about yesterday's tragic events at the navy yard, we're also thinking in particular of the brave men and women of our military and the sacrifices they make day in and day out on our behalf. once again i would like to extend condolence to the family and friends who lost their life lives or injured in the terrible, terrible shooting. know your country is with you in these most difficult moments. and also like, again, to express sincere gratitude to the first responder and medical personnel

and law enforcement officer from so many different agencies who worked together keep all of us informed. and most of all, safe throughout the day. >> flags across america are being flown at half has because of the terrible tragedy that cored out that door one and a half miles away yesterday. men and women who work for our department of defense to keep america safe reported to work as usual on a monday morning. then tragedy struck. the gunman appeared with an assault rifle, 12 innocent people died. another dozen or so seriously injured. this capitol of in shock. of it locked down at some point to ward off the possibility there were other shooters and more danger outside.

and we watched as the people who worked at the navy yard and those working in adjoining buildings waited patiently for the police to do their important and courageous work. at the end of the day they showed television footage of the employee being bust away from the navy yard to a safe metro location to return home. who sadly lost their lives to this senseless gun tragedy. we read the paper this morning trying to unwhat possibly could motivate a person to do this. as we read the background of the shooter, it was clear there were moment in his life when he used the firearm to shoot tire on a consider he thought shouldn't be parked in his driveway. and shoot a gun through the ceiling of his apartment went to the adjoining apartment. those might have been warning

signal. questions arise how can a man with that kind of a background end up getting the necessary security clarence for a military contractor to go to the navy yard to be permitted go to the navy yard? how did he get the weapons to the navy yard? an assault rifle and other firearms. questions that remain to be answered. god for bid we go on with business as usual today and not understand what happened yesterday. what happened yesterday brings in to question some important values in america. if we value our right for ourself and our families and children to be safe, if we value this institution, if we value the right of every american to enjoy their liberties with reasonable limitations, then we need to return to issues that are of importance. there have an issue before the senate several month ago bipartisan amendment offered by

senators machin and toomey. that would have taken a extra step to keep guns out of the hands of a history of felony or people who are mentally unstable. the vast majority of americans think it's common sense. we can protect the right of law-abiding citizens to use guns in a responsibling responsible, legal way for sporting, hunting and self-defense. we have to keep -- do everything we can to gun out of the hands of those who misused them. felons who have a history of misusing firearm. mentally unsubstantial who can't be trusted to have a firearm. but today we pause and reflect on the lives lost. i hope the lesson is learned. i had a hearing scheduled this morning before the senate judiciary committee on a controversial issue involving firearms. in light of what happened yesterday, in light of the uncertainty of our schedule today. i'm rescheduling that hearing.

it's an important one. i want to say to those following it that it will be rescheduled. that the point in time, we decided to postpone for today until another day in the near future. >> mr. president, i -- as we rise today i want to talk about the economy of the need to create an economic climate that encourages job growth and strengthen the mid class. before that i want to acknowledge as many of my colleagues have the tragedy that occurred at the washington navy yard yesterday. we're going debate a lot of issues, the business and the country goes on. the business of the senate goes on. but for the families of the victims of that tragedy yesterday, things stand still. it and it's important for all of us, i think, to take a moment and mourn with them the loss they have experienced and to extend our thoughts and prayers to their families and loved ones. it's horrible, horrible

tragedy. ooze we continue the back and forth we have on the issues and the day here, i hope, mr. president, we'll all remember and keep in our thoughts and prayers those families. >> mr. president, before i make my remarkses, i would like to senator thune and the others on the senate floor to express their compassion and sympathy to the survivors and victims of yesterday's terrible tragedy in washington navy yard. yesterday was another grim reminder of the dangerous society we live in and dangers that can confront us. and to be aware to make sure our environment is secure and safe. to those injured and sacrifice their live. may god bless their soul and in their recovery in the period they deal with the terrible tragedy. >> this weekend look for booktv's live full-day coverage of the national book festival.

looking ahead to october. >> young people, young children come up and said how can you be in the congress when you got arrested? you violated the law. i said, they were bad laws. they were customming, they were tradition. and we wanted -- [inaudible] to be better. we wanted america to live up to the declaration of independence. live up to our creed. make real our democracy. -- make it real. so when i got arrested the first time i felt free. i felt liberated. fad more than ever before i feel free and liberated. abraham lincoln 150 years ago

freed the slaves. it took the modern cay civil rights movement to free and liberate a nation. civil rights leader will be our in-depth guest sunday the 6th. heath take your calls and comment for three hour. also scheduled for in-depth, november 3rd, biographer. you're watching c-span2 with politic and public affair weekdaying featuring live coverage of the u.s. senate. a couple of weeks starting on act 1st. states will begin offering online health exchange for

consumers to purchase health insurance. one of the goal of the exchanges is to promote cost savings providing over the internet. the align for health reform hosted a discussion about the medicine. app new technology that could potentially reduce health care costs. this is an hour and 45 minutes. >> good afternoon. my name is ed. i'm with the alliance for health reform. i want to welcome you on behalf of senator rockefeller, senator blunt, our board of directors to this program to look at one of the most dynamic aspect of health care in america right now. i'm talking about tell health and tell medicine. when i first heard the term, more than twenty years ago, it was from the head of a west virginia university health system who explained to me this new system he was having installed all around the remote corners of that rural state to

make the rich resources of the university health system available to the remote areas with scarce or no resources. now, it is still important to rural area, for sure allowing better access to health care service. it may prize you to learn issue -- it surprised me that a patient benefiting from it was more likely to be an urban resident than a rural resident. the tasks accomplished through it were broader than a generation ago. everything from remote patient nosh -- monitoring to robotic surgery, it's better behavioral thoalt allowing primary care provider to consult with the most highly skilled, but distant, specialists around. we're less than 3 week weeks away from the scheduled

beginning of key component of the affordable care act. millions of people are projected to obtain health insurance coverage under the new law, and how will care be delivered to the millions? perhaps there is a partial answer in tell will health and tell medicine. there are potential barriers to tapping this new technology. erg from reimburgment practice is, licensure rule, cost factors. we're going to try to explore some of those in our discussion today. we're pleased to have as our partner -- the operator of blue cross blue shield plans in a doesn't states covering one in nine americans, i believe. you'll hear from john in a few minutes. let me just handle a little bit of housekeeping, first. in the fake et, you'll find a lot of good background

information including speaker bios, more extensive than i'm going have time to give them. and copies of the powerpoint presentations of the speakers. if you're watching on c-span, and you have access to a computer, if you go our website, allhealth.org, you can find the same presentation, the slides and follow along if you would like to. there will be -- for those in the room now and your colleague, you want to inform web cast that will be available on the same website in adjust couple of dais, and a transcript a few days after that. there are, in your packeted, green question cards you can use during an extensive q & a session to query one of the panel is or more. and a blue evaluation form i

hope you will fill out before you leave so we can improve the program and respond what you think we ought to be bringing to you in a way of topics and speakers. if you're part of the twitter verse, you can see on the screen there is a #hash tag #tellmed. let get to the -- we have a terrific panel for you today to discuss this issue, which is i.t. is complicated and multifaceted. i think we have a group that will be able to give you the using you need to pick this issue up and run with it. we're going start with neil.

he is the head of health tech strategy. information and management systems society foundation. better known and more economically known as hymns. he's been educating congressional audience on technical issues for as long as the audience has been around, for sure, in a series of briefings. we've asked him today to give us an overview of the state of tellhealth and tellmedicine. thank you for being part of the program. >> thank you, ed. t great to be invited back. i only have about an through do the presentation today and --

is he laughing? is ed laughing? we each have eight minute. i've, warned. i'll do this in that length of time. my presentation has to do with sort of the state of affair. such as it is or not many case over the years and that sort of thing. given what ed said maybe we should call it tellmedicine. t not just for rural anymore. truer words are never said. as folks from american tellmedicine would tell you, it's very much different than it was twenty years ago when i got started in the whole field. see if i can make this -- how i do make it go -- so we -- we talk about technology. we don't use it. at least not effectively. i don't recommend it for

anybody, actually. what is driving all of this ?ft health care reforms meet health i.t. starting in the lower right we're all concerned about some of the following. a 30,000 food level. public health or population health how we can drive personal health and consumer engagement. something for issue as long as i've been in health care which is more than thirty years. including things like personal status monitoring. i'll show you a couple of example from that. down as you continue around the circle, disaster preparedness, mitigation response, dod, va, nasa used to do a lot of work with nasa. and the triple name of the affordable care act and other reforms having to do with quality driving efficiency and providing access rural remolt

underserve desperate communities. which is a big for related technologies. okay. here is the definition. t morphed and changed a little bit over the years. it's the use of medical information exchange from one site or the other. the electronic communications to improve patient that status including things like video teleconferencing. transmission of -- e health including portal. monitoring of vital sign. continuing pl education and more. so we started exploring these issue, as ed mentioned in 1993 at the same time as the american tell medicine association was formed. we formed the capitol hill brown bag lunch series around it. all rural state u.s. senators starting with senator rockefeller, really, and kent conrad from north dakota, al simpson from wyoming, ted

stevens from alaska, mike, congressman from oklahoma. and some others. our first program and what are we going do about reimbursement and the more things change the more they stay the same. not as much reimbursed in twenty years. maybe they want to get in to that. we have done 190 lunch programs over that time. lunch demonstrations, phoenix week for your information, is nih key week in washington for those interested. we'll be doing showcases both up here on the center visitor center and the house side. we get the information online. here is the definition of a electronic health record by my current organization. the electronic record is a secure real-time point of care patient center information resource for clinicians. it automated and streamline the clay in addition's work flow.

it's not new. there are community health information networking that have come and gone over the years and all sort of earths; right. and the big trick is the convergence of technologies toward some of these overarching goals that i described in my first slide. this is a well-used slide by the officer of national coordinator. and the sharing or the interoperability of that information the data point at the end daft whether it's electronic data in a mm record or audio or video data in tell medicine. you start to capture that toward advanced clinical processes and improved outcome. these are stools -- tools that are meant to be enabled in a health care environment. nothing more. and so one of my thesis is that is the easy part. the technology is the easy

part. here is a little bit about that. i think karen may have some similar sides. lead hundred if not thousand of various technologies applications and content areas that substitute this growing field we don't know what to call it anymore. it's a $27 billion industry on the medicine side. if you look at the lower left and you see down there a wristwatch. that's for lifestyle management for runners like me. prevex, arguably, not a lot do with clinical care and the more fist skated applications as you move from left to right. or -- in erk irk chiropractic u or robotic surgery that started as

robotic surgery. very sophisticated. hundred of technology in that alone. my take away here is that the march of technology for health care far exceeds our ability to adopt, defuse, incorporate, and govern, here come the policy part, in a public and private sector setting. i'm the first person to prove you can do. my story starting a 74,000 and 200,000 years ago. and the guy on either side of me and women had wooden boxes with flex sincerity glass fronts with

electronics. can you guess what they were doing? they were all over them. they didn't care too much about the technology. anybody? the first pc. right. 1974. they were putting together the first pc. two thing about that, so the first is that, you know, if you do this and pursue this, what happens is you end up -- you should be like bill gates instead you are doing this. the second thing if you dress like this even then you'll never get a date. major policy issue. i have about a another minute. there's a whole series. i used the slide for about twenty years. having to do with reimbursement, put positively, there are no problems just insure insurmountable opportunity, and there a whole series of layers of federal state private sector level. i'll let you read them at the

leisure having to do with this. just yesterday congressman introduce legislation that make it easier for federal licensure for dod and va types. next week, next week a bipartisan bill will be introduced.

thank you so much. i'll be glad to answer any questions. >> thank you. >> we're going to turn now to -- [inaudible] and if you doubt that the roots of medicine and health are in rural america, note that sheryl heads the office for the advancement within the office of rural health policy within the

health resource services administration within the department of health and human services. [laughter] her agency presides within her is a. it's a focus of a lot of tell medicine activity. we asked her to guide us through some of the programs and initiatives that are mo -- most relevant. >> thank you very much for inviting me. i'm excited to see so many young people here. a lot of you grew up with technology. it's not as new to you as it is to some of us who are trying to catch up. i'm going to talk about the advancement. before i get started i'm going give you a quick overview. or health care p is office of health policy. her is hhs is the department of health and human services. you'll see that feds have a tendency to slide in to

acronyms. i want you to know what i'm talking about. why rush through my eight-minute i have to do at lightening speed. you'll know what, i mean. and also focus is not on the technology. the focus is on what the technology can do to improve the health. we have four different grant programs. these programs work together hand and glove to improve access

to health care for people through technology. i'll talk about the legislature grant program. it has awarded two three-year grant. one to the association of state and prevention psychology board. and the purpose of the grant program are to reduce or eliminate barrier across state licensure. that's to help facility other your in the try state area. they make it easier for patients to see their doctor no matter what mo dahl if i they use. right now we have twenty different grantees. we funded a new cohort of six and the purpose is to demonstrate how it be used to

improve access to health care. our grant funds go to support rules but it be located in the urban area or rural area. the funding is for up to four years at $250,000 a year. one of the things that we have done this year as a result of something i want to talk about later. we are able to shift the focus from does the technology work. we are at the point now we know the technology works. but how does it improve health outcome? is it the same as the visit. we are working on that now. we ask people to submit in the applications baseline data we're going follow it over the three-year period and use this cohort of six grantee as a test bit to the future. the grant program. this next slide talk about the resource center. that's one of my favorite grant

program. karen is one of the grantees. i'm sure shea going talk about the program. what they are are center of excellence. we have twelve regional or state-wide resource center and two national resource centers. one resource center just at the national center focuses on technology. and the other focuses on personal policy and the technology resource center they're there to help keep up to date with all of the technology -- as mentioning the technology e volving so fast we have difficulty coming up with words to describe it. the word evolve as the technology. the word come behind the technology. we have one resource center all they do is focus on the technology. it's available for everybody. that's funded through the assessment program. ttac. you can get to the resource center. additionally our policy resource center is medicaid reimbursement

document. that's where the center for the center for qebted health policy one again could be tell health resource center.org. you see the map there. the center have grown from just four resource centers to almost covering the entire country except for my home state of new jersey. maybe one day we'll be able to serve them. [laughter] scairn is generous. she keep taking more and more grants and states. she's able to help them. she's great at helping them. we don't have any money. we don't even -- anyway. no matter where you are in the country, if you need help, if you're interested in starting the program, you can go to online. you find your statewide or regional resource center and also they have monthly web are in. you can log in to any time. they have the information archive. they are a great resource.

i high will recommend you check it out. that's a brand -- it's not really brand new. just funded second cohort of grantee grantees. it was announced yesterday that the winners cost hort are alaska, maine, and montana. the first one -- the first round of the grantee were alaska, virginia, and montana. the purpose for the grant program is to make sure that veterans that live in rural areas have access to health care services via tell health. no matter what weather they are close to the visit or not. there are a lot of rules, you know, we want to make sure that veterans don't have to drive a large amount of distance to get to the health care they deserve. so we're working very, very closely in partnership with the veterans administration to make sure that these grantees and the veterans in the state have ak sties to health care services no

matter where they're localed. another thing we have done is last year we were able to have a issue for the institute of medicine. did a two-day workshop on the evolving health care environment. the chair of the planning committee, and tracy is our iowa contact. he's in the audience. we a great two-day meeting and it was published. here it is. it was available made available in november. and anybody wants to know anything about the -- if you want to get a copy for yourself. you can download it for free. go to the institute of medicine website and google it. it will be free pdf download. one of the things that came out of the meeting that was so important. there needs to be more of an evident-based that looked at outcome of health care delivered via tele health. of it a direct as a result of

what came out of the institute of medicine two-day workshop inspect is a great resource. i highly tremed. anybody check it out. download it, there's a couple of copieses in the room. feel free to thumb through and talk a look. it's a great resource available. which reference briefly. what it is is -- when i started the job about three years ago, not only if i want to know what was going on my office i wanted to know what was going on across the federal government with regard to it. what we did we called all the people that were sport part and said what is happening? would you like to know what is going on with other part of the government? we had an overwhelming response. we have been meeting for two years now. we meet every other month. then we have meet they to face

twice a year. we have representatives from c vrng c, va, cms, commerce, justice, it's amazing how many different federal agencies have an investment. we every other month and have two speakers that present and talk about what we're doing in our own offices. then we talk about work on it together. what is it we're working on. the paper on the -- thank you very much. by the way, let me endorse your endorsement of the this iom report. it's a terrific resource. it has everything you want to know at this level about what the issues are.

and t readable. at the lefm that frankly some institute of medicine documents might not be from time to time. i guess that is a trigger for introducing the chair the planning committee of the workshop. dr. karen. she has a long list of accomplishments. i commend the buygraphic call information in your kits to you about her. her primary connection with us today is her position as director of the center for university of virginia. there are 108 sites in uva tell medicine networking. we're looking to hear about among other things some of the day-to-day challenges and the policy barriers that exist in

trying to make the big use. thank you so much for coming with us. can you marry me? perfect. it's a privilege to be here. thank you for invite me in and joining us today. t ab important issue as we look at access to health care services and access and post affordable care act. our program was established almost twenty years ago. and you have fought the battle and talk the talk and walk the walk as best as we can. we have faced challenge and many successes as well. i would like that say that we are proxy for many programs around the country.

who the primary beneficiary? it's the patient. it allow for time -- home bound patient as well. patients are satisfactoried the burden and cost of transportation. improve quality care and increase patient choice. for health professional there are benefits as well as especially in the era of huge work force shortages. it's a huge benefit as well. more than 90% engaged in the stay in the community settings. that's important for family. it's important for community health care system. it drives broadband adoption. and it creates an enhanced health care environment. an economic impairment for the community. again,, the program is are proxy

it for many across the nation. we offer video conferences. the traps for of medical image and medical data for interpretation and classic example is tell raid controls. there are many applications. we have established a patient monitoring program. we call it the c3 site

networking and the commonwealth of virginia and technology doesn't have to be in our traditional referral area which has been the western half of the commonwealth of virginia. we have preponderance of sites in far southwest virginia. primarily because that's -- at least when we started it was a rural area and a lot of grant fund and legislative partners in southwest virginia. we have sites in the mightd of the bay and eastern shore of virginia as well. so technology while this is not about technology. it's important choose technology that are interoperateble. that has been our guiding force to two thingses that work with one another. plug and play. there's a continue health alliance of equipment manufacturing that pledged to create interoperateble devices. we have desk top video conferencing, mobile video

conferencing, fixed video conferences and ipad and other tablet devices. we have used robotic technologies as well. as far as our dash board, we have supported more than 33,000 patients encounters. and when we first started program we county connect to a lot of site. the volume are rather low. i think this is very interesting between 2011 and 2012, one of our fellow went to private practice. she took a fair amount of business. i would say it's work force development. she's serving patients in virginia. that's a good thing. we're marching back up again. more than 40 specialties participate in the program at the university of virginia. and metric i want to share with you which we're proud of. we saved virginia patients more than 7.9 million mights driving for access to health care. that's a lot of dollars transportation cost for the medicaid program and patients as

well. it's metrics driven. you have heard about clinical data being important in evaluation. and quick example high-risk mel sin we reduced it by 25% in the networking. it translates to healthier baseballs and mother. lower cost for the medicaid program. these are just two of the 40% specialty. connecting rural community hospital improve access to the use of tta. and we have increased the use of tpa from 0 to 17% of stroke patients that show up in the hospitals. huge outcome in benefit to patients. i mentioned remote patient monitoring. it's a very effective tool for chronic disease management and post affordable care act. very important for hospitals around the country. because there are penalties for readmission that our hospitals are facing. it's a fabulous tool to reduce

readmission, reduce er visit and there's a lot of data those from the va and academic hospital that show a tremendous reduction emergency emergency room visits and rehospitalization. so we believe it should be a state and federally based and market driven service line. our commonwealth of virginia has been supportive of it since really the inception our policeman. -- program. in particular under the governor's administration he expanded. is anybody here from senator warner's office? when he was governor -- for medicaid beneficiary. they are now eligible to receive the services anywhere in the commonwealth of virginia. we have negotiated -- anybody from cmf? we have negotiated in our dual enrollee contract which is medicaid and medicare patient. we have 77,000 covered in virginia.

they are covered under medicaid in virginia. why not under medicare. tune in. we hope to have the announcement shortly. virginia department of health has been supportive and consult origination site pen on the south side and southwest virginia. our joint commission on health care which is a virginia legislative body did a work force analysis and created a road map for what ultimately became virginia mandate and passed in 2010 from the virginia general assembly to mandate third party payment of services. we're grateful for that. our virginia health reform initiative and the health benefit exchange collude -- include. i mentioned the virginia health work force development initiative.

so we wouldn't not be where we are without the federal government. we have received grant funding from u.s. department of agriculture, usda, they funded rural phone service. they have a distant learning. we have relied on it for the procurement of equipment remotely. and nih. all the federal agencies have some involvement. and she talked about 16 agencies and departments. there at least 16 agencies with some involvement in telehealth. a huge shout you to the tracy and the iom. of it awesome for us. one of the things we need more than anything else. we are trying to advance it nationwide is improve medicare reimbursement. it's still low. in 2011, cms reported less than 6 million in reimbursement for

telehealth services nationwide. it's not very much. one of the challenges are some of the limitations that originating site. some of the rural requirement for telemedicine and the definition of rural. i'm thrilled the 2014 physician proposed payment rule has an expansion in the rural definition which is currently nonmetropolitan statistical area. and there's a rural requirement for aco. the changing definition of rural limits the sustainability possibility and more importantly access to care for our vulnerable seniors. so and also the rural definition is poorly aligned with specialty work force shortages. so there are many issues that need to be addressed. reimbursement being one. credentialing and privileging, cms issued a new regulation two years ago which was -- we obviously have to be aware of hipaa. license affordable is a

challenge. medical malpractice is a challenge. if we go across state border we need to be aware of the malpractice cap in other states. we can't buy equipment for a viewing site. it uses very important. the fcc has a wonderful program. it provides discount for rural providers. they teached on it. and health information exchange. wouldn't it be nice to call up the continuity of care document when we see a patient. we are in the state moving forward toward hie. and plea for -- great opportunities for the national organization the black erected women. legislative women have model legislation in the states and now 19 states plus the district of columbia have passed a mandate. congressman harper telehealth enhancement act about to be

introduced. ..

>> thank you very much. i will make myself available at any time. thank you. >> thank you, karen. finally we will hear from the vice president of provider engagement strategies for well points. well point being not only our partner in today's program, but the outfit that has charged john with finding ways to improve care and affordability and improve consumer experience it's pretty big job for a company that insures one out of every nine americans. john has developed a response to that charge and he had the wellpoint's that is designed to be with doctors and consumers and we have asked him to tell us

about his those evarts today. thank you for coming at us. >> thank you. good afternoon, everyone. we will tell you a little bit about it. i had mentioned some of the key points here. so from a health plan perspective, you may not know this, but the health plans are often looking for ways to make health care more affordable to improve access to care and also to improve the customer experience especially in the event of the oncoming of exchanges where consumers are going to choose a health plan one by one. we are fortunate that well point to have a family of blue cross affiliates across the country that tend to attract a lot of the best and brightest ideas in the market that we get to take a look at. i was very fortunate to run into a company in boston called american well. it's a technology company, it builds an online care platform

that really redefines tele- medicine. so i will share that with you and help you to understand why. so we work with american help and we built this product. the question is, well, what is the live live help online. well, it's you, friday night. you are at home and you do not feel well. and today you have a couple of options. you can go to an emergency room and it will cost a lot of money and you will sit for a couple of hours and you'll way. you can find an urgent care center or happens to be one around that is open. it was still cost about $120. maybe you live near walgreens or another retail program clinic. there is another option, you can see a nurse practitioner. you will wait away for an hour. you have to drive there. or you can do nothing.

we have introduced a fourth option. you can open up your laptop or the webcam order your mobile device, tablet or telephone, cell phone, rather, with and have near immediate access to a board-certified primary care doctor on demand from the comfort of wherever you are. your home, your hotel, wherever you are. right now, that is priced at about $49. so it is affordability and gives you a affordable options that consumers have. it gives you more access to care. and it improves the consumer experience. people value their time more than anything. currently the doctor cannot put hands on the patient on the blood, so there are indications as to what can be seen. but there are an awful lot of things that people would feel a lot better about if they could just talk to a doctor.

and often times we would have a hard time getting into it with your doctor even the next day. based on the information you exchange with them in live real-time audio and video, it can be used for them to write a prescription to help them feel better and it will be electronically sent to the pharmacy that you choose and if the payment is done by credit card, it may be integrated and that claim will be submitted and you will only be charged co-pay. no paperwork involved. if it sounds too good to be true, it really is happening. we are live in ohio and california we are introducing us

to international employers anyone can use this as a consumer i will talk to you more about that in a second. the ones that matter in this discussion? because you hear a lot of talk. there has been so much wonderful work done bringing people access in rural areas to urban doctors improving access to care. and the barrier to that is that you need grants and money and you have to put expensive equipment in one site and expensive equipment in another. people still have to drive. this idea of originating all goes away within a technology that's coming. so thanks to people like steve

jobs at apple, high definition video compression, high-speed internet, the bandwidth keeps improving. many of you space-time or skype. if you think about those technologies in a secure structured manner built for health care, that enables people to no longer need grants to put a lot of expensive equipment around. you can think about a medicaid plan and you could go to a public library and put an icon in the room. and you suddenly have a virtual clinic. you can attach biometric devices, a stethoscope, some other things, you could even have a nurse there and expand further. so i want much water couple of slides and give you more insight. this is meeting consumers wherever they are whether you're at home or at work. it addresses convenience. there are many people because of barriers to transportation and barriers to care, they just

don't get seen. at that price point when you avoid an unnecessary care visit, you're actually saving money in the patient enjoys the experience. these are some of the points we give our sales people when they are talking to employers. their other solutions out there. some are purely telephonic. you make sure that they know the strength of what we have here with live help online. i will let you read that on your own for the sake of time. this is really the key screen, the home screen when you log in and it matches you up with the district of columbia with where you live. we will show you doctors that are licensed in that area. right now the model is, if you will, urgent care enough clout, kindercare, urgent care, the kinds of things that can be treated. think about things like

behavioral health, it is fascinating how the mind against work when you start thinking about it. i had people telling me two years ago who would ever get care like this. somewhere in between here and there is the truth. we could see the doctors up front, read about them, find out where they went to medical school and it's very important to the consumer experience. so there are solutions out there where you dial an 800 number and someone has the doctor call you back if you have never heard of, we are trying to achieve something that is really better than not. you go online in the register and it costs nothing and it takes just a couple of minutes.

then you have it whenever you need it. again, i mentioned an ils and android platform coming next month. final testing stages are being tested right now and i think that that will be very powerful. because an ipod and ipod is one of the simplest conferencing devices. you wouldn't have to teach her mother to do anything. you turn it on and it's ready to go. this is really important. so there are asterisks in some states, some are red. let me just tell you what next nine seconds what the issue is here. with medical boards, pharmacy boards, around tele- health, they have so many different definitions and it's impossible to decipher what is allowed and what is not. but if we are going to go into a market and have doctors practicing this way, we don't want to put them in a position to jeopardize their license. so many of these rules have

terms like originating sites that apply to the old technology but not the new. what i would ask this group to stay tuned about and to help with all of them is what's come up with a modern definition of tele- health that doesn't talk about originating this. we are working with the family practice and organized medicine as well. can a doctor through either active technology gain enough information to examine a patient and if so, that should be how we define it. and what are those things need to be rounded but are important? welcome we have that information we can share draft with you. and is there doctor have enough to write a prescription. not for viagra, but for noncontrolled medications that will help that patient's

problem. if so, let's let the doctor use their judgment to do that. that is what we are seeking. that is what we are involved in in this activity. my time is up, thank you very much. we will be talking later. >> thank you so much, john. one of the nice aspects of the format is that you will get a second bite of the apple and we'll see if you can get the first byte of the apple we get into the questions and answers. there is a green card and the material is and you can write on it. someone will pluck it from your fingers and someone will bring it forward for a response. or we have some microphones there and there. on either side of the room. if you come to the microphone, try to get the questions as brief as you can so we can get through as many as we possibly can. please identify yourself.

and let me start us off, if i can. john made repeated references to something that was mentioned earlier as well. and that was originating site. i'm i'm wondering if i could ask whoever feels the urge on our panel to tell us a little bit more tangibly, how is tele-health reimbursed now under medicare and under medicaid, if there is not an answer to god for his hard as it is with other answers, 51 different answers. >> okay, so for medicare, the specific number of originating practitioners, clinics, communities, health centers, hospitals under medicare.

for the reimbursement there is only a set number of types of providers that can be reimbursed under medicare. then medicare puts a limit in terms of the location and that is where it currently is the definition of rural. again, that is a bit of a challenge for us. it's not an originating site under medicare. under medicaid it is also up to the states to make that decision. the 50 states in 50 different definitions. in virginia it is primarily clinics and hospitals and community health centers, mental health centers, and again, it's not at home, but we have gotten approval to do patient monitoring in the home. and we haven't really tested the private payers get. that certainly virginia is one of the states that is covered under your collaboration. so certainly for your program,

this is a knowledgeable site not under medicare. >> yes, so we made a bold move in being the first pair nationally to commit to reimburse them for these online services that i just described. the reason was i spent a lot of time with doctors over the years and they say, why don't you pay us for telephonic care. we are doing so much on the phone for work. mothers want to bring their children into the office because that's the only way we can get paid. quite frankly the answer is rational. we don't know what happens on the phone. did you talk for two minutes? did you talk for 20 minutes? how much cognitive thinking was involved? if payers say, okay, we will pay for a telephonic minister, what does that mean? with this kind of technology that i described, when there is documentation of the patient's complaint and the doctor has just reviewed, the doctor and the patient have a live video interaction that the doctor

makes and creates a medical record from not. if there is a prescription written, it is described and documented and there is a permanent record. so many things are built into that technology that we felt comfortable saying, well, that is a visit. whether it's in the building or not, in the same room, we really don't care. and there is a cpt code for that. it is 99444 and that is online here. so that makes sense from a private payers standpoint and we have national employers to agree. >> one other thing, a skilled nursing facility is also part of an eligible originating site and then we built you none codes with a modifier. >> so here's my quick answer to that. technology eliminates time and distance to the point where we need to stop thinking about everything being done remotely. it doesn't matter if the patient

is here and the clinician is in india. if you get enough of the right and correct information. endoscopic surgery within the operating room as telemedicine. image goes all the way from inside the patient to the physician, who is viewing it on a screen and no more than 5 feet and what is the difference and there is none. that is the short answer. a limited number of sites and codes through a patchwork of crazyquilt stuff and the states around medicare and medicaid and private insurers are trying to scratch their heads and say how do we make sense of this nationally in the short answer is that we have to get a handle on this. i think john's suggestion that we start to deal with what it is and begin paying for it, that is the only rational one. we have to deal with the

licensure as part of that and stop dickensian practice of state-by-state licensure, which has zero to do with science or health or the human body and everything to do with business practices and states by physicians. it is time to stop that. [applause] >> i don't want to tromp on either of the questioners waiting, but getting back to the wine, medicare differentiates one place from another. and we know that the payments vary substantially from one market to another. what rate applies when you are in one county and your patient is in another county's? is at the originating site or is that not a consideration?

>> pnm code with the gt modifier, for medicaid, if we are paying it, the same is true for private pay as well. as part of the mandate of the parity legislation. >> and it doesn't make any difference, for example, if you are in upstate new york were in manhattan, presumably the rates for particular service are different? >> whatever it would've been, if the university of virginia is building a telemedicine could come at the same as if we did the face-to-face. >> okay. i think that concept of site of service code would become obsolete as neil was saying. it had to do with how much resources we were using. that meant it was part of the hospital and there was a little bear for overhead. and then there was outpatient. when you get into this, what does it matter whether it was a

hotel or home or down the hall here in a quiet room. i don't think that it will serve as if we can't come up with enough place of service codes. but that will be for another day. sumac all right, you have been very patient. please identify yourself and ask your question. >> thank you. in regards to this last point. i think this question is more geared towards the other type of telemedicine. not towards endoscopic procedure. so i notice that in your slide to talk about there are some good outcome measures and i'm wondering about one other piece of data, which is the total cost of care. specifically what sort of data do you have either now or forthcoming that would describe in the latter part the definition of the definition of tele-health, the effect you can have and i would assume that in john's example that he did the

analysis and the folks at wellpoint decided that this will be better for our quality of. so i'm wondering was there a point where you think there is a point where the returns occur, where the needs of the patient are such that they are really improving in quality and how do you do this for your patience for participating in the program. this. >> i will take the first one. thank you. let me just say that it makes sense even if it breaks even. if it did nothing for the cost of care but improves affordability and let's say it improves the consumer experience and it widens access to care, that would be good enough. there isn't affordability at play here. wonder their study with her own

employees and after each online service that, we asked the question, if this was not available, what would you have done. so we quantify that and we ran across our numbers. a small number would of went to the e.r., large chunk would've ld hnte waited a day and gone to got to the office. some would've done nothing. new costs were incurred for people who might not have done anything. net net, when you added add it up on average, you are saving anywhere from 45 to 100 hours for every online service that of avoidable other costs and not just for primary care. so that makes it makes sense. it also makes us targets your questions. those that are going to the e.r. for nonemergencies, let's at least reach out and make them aware that there is another solution. this is really about marketing and creating consumer demand.

if you look at the original days of amazon.com, it is very flat for five years. then it went like that. really it will be the consumer to decide we want to make sure that we get it to people who need it the most. >> i am not a health economist, but i will till you that we have tried to get a lot of this data. so we can extrapolate if we reduce the burden of preterm delivery and we reduce hospitalization for patients dealing with stroke. it's those who have a comprehensive look at the data and we tried recently to gather data for a proposal on telemedicine. it was very difficult to get cost of care even from the medicaid program on baby who didn't get hospitalized at the hospital because they ended up being bored in their community at term. attaching event numbers to the mother. many of them are a hospital system and not getting a pair together. that we are trying our darndest.

so we had seen the tremendous cost savings are worth associated and it is very hard to gather that data just because of a mix of patients and payers and hospitals. >> one more thing to factor in. it is productivity. with teachers unions, they have to take four hours or a have they pto they need to go to the doctor. if the teacher doesn't want to use a precious half-day vacation time to go to the doctor, they are gone. on average they are gone 90 minutes to two hours. so we are actually commencing this study as we roll this out with some smart people and some actuaries to be able to come back to in a year with some sound data. >> yes, unless it is by the

medicaid program or the correctional program. >> yes, it is difficult for economists and folks who have done those kinds of studies. there are antidotal studies and it's great that we are finally now starting to get some of that data. but frankly the industry has fallen short in that department and we have not committed enough resources to it. that being said, we knew in the back of our minds at the congressional that the congressional budget office was not necessarily point to consider any of that forward thinking work forward leaning information. that is not how cbo's going on. it's a major legislative fight that is also looming in the background and has for 20 years. something that affects health care probably. so how does it consider that when it comes to other legislation and that kind of thing. but we have to get our act together in that department.

>> yes, go right ahead. >> hello, i'm laura wilson from the department of health and human services. he had mentioned the role of tele-health and i was wondering if you could speak to this. >> there have been good examples, many conferences and is that how you say it? the disaster preparedness act from four or five years ago and there are examples from within and between aware, for example, clinics in new orleans and some hospitals who had some of the early grants that no longer exist, the community development grants. they have used some of that for the tele-health like activities and actually preserved their systems when all else went down. the tornadoes rose recently in the midwest a year ago, there are some very good examples of this angels program that i have been one of my slides and others, some that include

earthquakes, nasa, about 15 years ago, we started to become involved to russia order to "new york times" reporter had gotten shot in senator rockerfeller sat there and talked to "new york times" reporter. this is pretty diplomatic. he was sitting there and this is 20 years ago. a long history of nasa using it in somalia, bosnia, and almost every deployment. there is a whole discipline and it is involved in the state department and the various multilateral organizations and overseas governments around justice issue. >> the commonwealth of virginia

has invested emergency preparedness dollars, all the hospitals, almost every hospital is connected and we test regularly for disaster preparedness so that we can manage and triage together. when you think about it also, look at the data that can be mined in terms of surveillance. pharmacy utilization and other outbreaks. these networks can be used to increase awareness in a very timely fashion. >> yes, it is the low hanging fruit in many ways. especially with electronic health records because you don't have some of the same business and other issues that you otherwise face with competing interests in various locations around the surveillance and community care records and that sort of thing. that's a really good place to start where there is a common level of expectations and

people's interests and those types of things. >> cohead. >> hello, i am a pediatric hematologist with johnson health policy center. i was thinking of prescribing antibiotics for it or infection. so clearly there are going to be examples where you are going to miss medical problems he might not miss if you actually examined the patient. you envision a separate standard of care for telemedicine actions as opposed to the one where you actually see a patient has that been a problem in virginia? >> i will start. okay. making sure that i clarify that i am not a physician. i will tell you that our goal here, the point is to allow the doctor to use their clinical judgment based on the amount of information that they can use

through the interaction. if they don't leave that they can adequately diagnose and that they should not prescribe an antibiotic, then that's exactly what they should do. the technology simply enables a person to get in front of the doctor for many things that can be described and diagnosed by listening to the patient, seeing the patient, and it's up to the practicing doctor and a practicing standard of change. most of us that work with computers, that's most in this room, we don't often have live webcams in our workplace now responding to that call. there are some very interesting and fascinating designs and we have some of the slides to take a look at. you have a digital dermis scope

and some additional per friel's that will give the doctor more information. think about an employer that could not afford a worksite clinic because the cost of employing the doctor and the nurse and all of that now, if they set up a quiet room with basic technology and the internet, it can have a nurse or a medical assistant take vitals and do something to expand what the doctor can treat. what can they obtain and what are they comfortable with treating. >> i'm a pediatrician as well. we have used a stethoscope and that is a slightly different model that i think works, but yours works for triage. but we don't establish a separate standard of care. we want them to have as much information and to be able to manage a patient as well as they could in their own office.

>> in no way is it designed to replace someone's primary care care. but there are some who take phone calls today and the right antibiotics without having seen the patient and the list goes on. whatever the standard is we're not trying to change. in terms of the quality, that is what we all care about, do no harm, make things better, which in some cases, like in mental health care, they actually think that oddly it is more receptive and it can be better with consulates and some things. but there is a role and there has been an ongoing discussion with mobile and wireless technologies and what buckets they will fall into and that is a really good discussion point

in which to enter. many of them now, all of them are actively engaged in how to we sort of ferret out those issues and how does that all relate to the other matrix better in the informal care act. >> yes. okay, a pediatric cardiologist. this is a physician taking a call like they used to before they went to nursing centers as opposed when he took calls and i took calls, we were not reimbursed for it? >> our colleagues, they had a huge difference in terms of what a physician can evaluate over the telephone and a picture is work at him with a thousand words. including practice guidelines and a whole host of specialties,

including primary care and urgent care. most have private guidelines in a number of different specialties. if anything, i would say that we are improving the standard of care in many communities. but a patient is being treated in the local community for shingles. they did not get better and they asked for an emergency consult and saw a dermatologist and it was flesh eating strep. not shingles. so suddenly the access is really life savings and that really works in terms of our country. >> can i ask if we could segue to a question that is on point here. and also the previous question about data of costs. are there studies that are

available whether it was a population basis or anything else that described the impact of telemedicine on outcomes. are people getting better? are we -- are we imposing quality standards? >> there are standards. many of them. >> absolutely, i think there are not a lot of studies because the environment has changed. there are groups that are doing studies on these various issues. >> many of them are documented in the journal of telemedicine and it has been in medicine for 15 or 20 years. there are many good qualities

for outcomes, like studies, it shows the benefits of various teleology's in the different disciplines. >> there's a whole chapter on the current evidence-based. >> thank you for bringing that up. one of the reasons that i wanted to get to that question is not summary at least some of the participants, some have been talking about how robust the evidence was. is that still a fair concern was that one of the major takeaways or are we had a position where he can make those judgments? >> well, we had a very comprehensive discussion about what was well done. and it just pointed out to the fact that many studies have been done.

but there is room for more to be done in terms of larger studies and economic analysis as well. >> absolutely. there is a role for it quality both within the current mandate of the billion plus dollars under high-tech funds for these sorts of things, whether or not it is on point. a lot of it has to do with a chinese hiv somethings, and other directive kinds of things should technology and science policy in the white house take place, in terms of just energizing that evidence-based, it has to be done. >> of your left arm is holding out so you can keep the last thought there, i think this lady was at the microphone first. >> good afternoon, my name is jackie watson and i'm the executive director for the board of medicine at the district of columbia. thank you to the panelists for the informed presentation.

this question is for mr. newberger. he made a comment about state licensure and i'm a great proponent of telemedicine and i just wanted to explore with you your recommendation for how licensure should be handled for physicians. and probably more importantly, the disciplinary aspect, how do states actually control and regulate those who may not be licensed that have performed for these outcomes in the state. how are those issues to be handled? >> okay, so there is at least come i don't actually know the current status, some progress within at least one of the councils of the committee of the medical association to at least explore the holmes licensing and compact which has not been that widely adopted but perhaps 12 or 15 states in last 12 or 15

years. allowing reciprocity of interchange for licensors and things. i think we have to get more real about going down that road so that there is that sort of reciprocity were some sort of generalized system to start to approach it. it's been too long. and in terms of disciplinary actions, métis ata and m.a. ama and others, it can be done. >> that is a challenging part. i think most people believe that a doctor licensing colorado, they should be able to get a license in the district of columbia or maryland. but the only control what they have over the provider, unless they are licensed in the state, and each state has different laws and rules around to discipline. the challenge is it is not a big deal because you take it and you

pretty much it standardized now. but the discipline part is the issue. i would say that it really isn't to make money but to protect the public. that is the aspect that we looked at. >> i don't mean this, but they are protecting the making of money in some ways. like in places like california they have too many clinicians but not enough of the right kind order to distribute the right kind in some inner-city areas and so forth. so it could be viewed at those laws are archaic, they stem from the 40s and 50s. they were a construct of state medical associations. and they fell out of the backside of medical associations and that has to all be reviewed, including the disciplinary aspect. >> i think that some need some help and they understand the

importance of the technology, getting access to care. the issue is that we are in a position where we get complaints. we have to be able to address those complaints and we can only do that and have control over the person who is licensed in our state. so that is a challenging part. whoever comes up with that. >> guest. >> the gentleman with the laptop. you have been waiting. >> thank you, i have seen health care providers embrace new technology and some who do not. what demographics of doctors have you seen and who are the doctors embracing this? >> tele-health is such a broad term. i think karen and others can speak to the specialties. this is a fascinating time for doctors. working with a group in indiana, and they have over 200 doctors

and their experience has been that the average length of career for the working mom working parent is about 10 years. after having a second or third child, they have come to the practice in those hours, there is a physician shortage in health care reform will more people to try to get appointments coming, yet we had these highly trained and able to parents who are no longer in the workforce because of brick and mortar time distance. this is a group that is very interested in practicing evenings after the kids are in bed, maybe weekends. tapping into that. if a physician with a disability who has trouble getting from room to room in the office, but is now a standing position. positions who are maybe thinking

about retirement or lifestyle and don't want to have a staff and an office and all the expense of overhead. so it allows you to suddenly start this along with other great physicians who dislike the idea. >> behavioral health, mental health has been surprisingly robust. and we have chart like this, don't we? that have bar graphs that show the adoption rates, which we can get for you off-line. but correctional health is big and one of the early things. in primary care, as john said. so that parents, as karen said, of newborns and others can monitor the mcu or adult icu and monitoring in that sort of thing. there are a bunch of subspecialties that are just

kind of taken off. promote monitoring for cardiac patients. what else? >> i would like to address the greater versus non-gray-haired positions. it has been phenomenal. we have as many gray-haired positions that don't say no to us. but this younger generation, the good news is with the proliferation of hd videoconferencing, being there is like really being there. for those of us, who were driving all over before, it's a whole lot better and we can do it by a video teleconferencing. i think the option is pretty uniform may be driven by the end of the generation. it is much more creative and generating this as well. >> there are several questions that have to do with payment.

we have talked a little bit about that. one question has added space. the question about moving towards captaining payments, it would free up some of the restrictions that we have heard today that flow from a lack of reimbursement for a particular service for a particular professional. >> i would like to make a comment. if you talk about the accountable care organizations, we need other changes and i think in the captiva model it's a great idea, but we still have a way to go. >> you are talking about medicare? >> yes, private a seo's that are almost as numerous. >> i don't know that information >> to some have every sort of

thing you can imagine going on as far as i know in terms of monitoring technologies. medicare model homes, all of it. and the thing is it is a really pressing question because it may be that the ground is changing up from under us. as i mentioned two others, we have been waiting for fee-for-service reimbursement to sort of make some sense and not be incrementally done thanks to senators conrad and stevens and others, the ground is shifting. so we can't let this train passes by without consideration in all the various shared savings models that are being so actively pursued both within the accountable track and also in the private sector. it doesn't matter what you think of the accountable track. it's happening in the public and

private sector. >> look at it as a power tool to the physician that is in decapitated environment. it's a matter of getting the money right. if our health plans were rolling out these primary care models across the country, but what it means is that now when the doctor is tired at the end of the night and he goes on to eat dinner, they are still worried about where the patients will end up. before it didn't matter to them. but if they wind up in the urgent care and they didn't need to be and it is taking thousands of dollars out of the risk share and they are responsible for this cost of care, knowing that they had a service to refer to a new wanted to go home, whether board-certified doctors, not threatening to take them away, that they would be able to see

the chart in the morning. it is really a very helpful thing. then those practices that do want to provide that care, they no longer have to say that we have these locations and everyone has to drive in it. and now they're actually able to capture evidence for the people that would've wandered into the e.r. urgent care and keep it in their practice. so provides a lot of flexibility for that. >> the other is managed medicaid. if the medicaid program dozen doors telemedicine, that is a managed care model that works very well. >> let me add one about high-tech and disconnects if i could. it does a lot of good things, 33.5 billion that is right for

medicare and medicaid adoption of meaningful users of three stages of adoption of information technology. for no good reason but the speed with which it was done and lack of funding and all the rest, there were some groups that were on the outside looking in including more complicated with continuity of care from the national association of home care. home care and nursing homes on the outside looking in, as is behavioral health and emergency medical providers. a couple of other categories like nurse practitioners and others and telemedicine to a degree because it's not really mentioned were talked about in high-tech. but it is more so in the of affordable care act.

these are some things that include the alignments and the various reimbursements and other models as we look at these various laws for continuity and to see whether we are pulling this out and the goals of having care be part of the system is. >> we are not going to get to all of us. this is something that cannot wait. we are going to go to the microphones in the next 15 minutes. let's take the questions that are least amenable and you think that that will change with new technology? >> well, if you look at our model and pie chart that we had earlier, more than 50% have been in the behavioral health spears.

that we have to feel a nodule, we have done some research and that is really not proliferated yet as part of a general practice. so frankly if they need surgery, yes, you need to see a surgeon in a hospital, especially surgeon that you need. so while there is robotic surgery, it is not mainstream that we do connecting the low hospitals. but you have to feel it and it's probably best to actually travel. some of our specialists request of the first be face-to-face in the office and it just depends on the specialties and the comfort level of the provider. forty of our specialties actually participate. >> do any beaufort sea they're

coming a day when the consumer may pay a penalty to actually visit a doctor as compared to tele-health? is that right? you will pay a premium. what you think? >> i don't see it that way. but i see these as a series of tools that enable health care and the changing advancing goals of health care. including nurses that provide a lot of that hand on care and allied practitioners. the notion that the technology will somehow replace the clinician is, to my mind, absurd. i was reading about poker machines and not is not health care. and in reference to what they are doing, it is still -- there

there's still judgment involved. there is still things that are going to have to take place and that is what consumers want. so i just don't see a. >> okay, we have someone who positively had to get their questions answered. so let me just say that i would appreciate it if you listen to the question and response, he plucked the evaluation form out of your packet while you are listening. >> hello, knew my name is kenneth and i am an intern with the aba commission on online aging. the general question. has any thought been given to those older americans, especially those who live in colder areas that may not have access to an apple store or a best buy to purchase these materials, will they be completely excluded because of

their lack of technology? >> okay, chapter 11 about two years ago discusses this related issue at some point. it is sort of the need to level the playing field in terms of rural older populations who, for a lot of reasons, cannot take good care. not enough technical support, as you mentioned. they don't have access to broadband computers and all the rest may not be technology savvy and that sort of thing. historically there has been -- studies have shown that the minority populations have been far less. but there is some good news. but the mobile telephony is a re-plugged technology and at

least some of those problems that i just mentioned like broadband communications and whatever connections are out in the rural areas. we see these in africa and asia and a commend this explosion, like billions of handsets. it's incredible. two or three for everyone on the planet or something. in wireless mobile technologies. so that may be an instance where the technology actually offers a really good solution to the problem that you describe, which is that sort of access and everyone has smart phones now. >> there are some terrific programs and involves a qualified health care center and then subsequently the health care system. she used algorithms to identify

the most at-risk patients and in cooperation with the hospital and the nurse, and the patient's home of technology and train them how to use it and actually they took the most vulnerable patients and had the best outcomes. so we shouldn't give up on those patients. as the affordable care act and implementation happened with penalties, these systems embrace these technologies and i think you'll see more projects going forward. >> there are provisions that require one of many reports to the senate and house, human resources and the senate finance appropriations and the staff in the room holds the various agencies when it comes to that kind of reporting. it's just that they've all been so busy standing up the meaningful use of other related

kinds of efforts, it is all something it had a chance to do. and there are rule efforts, not only driven, but also at the veterans health administration that is a lot of money for rural veterans. so the agencies are well aware of the resources and focuses of attention. >> for those of you that don't have an acronym last in front of you. some of you may not know that high-tech in this context is not an adjective but a noun. it is a piece of legislation. as we try to follow up on this question, because we have several asking about different aspects of the fcc's involvement of this issue. how persistent is the lack of a

durable broadband availability in rural areas? is it still the problem that was two or three years ago? >> i think not. not as much. there are like 7 million out of the stimulus that was made available not to the learning and links program which is a telemedicine program, but for broadband into rural areas and through the commerce department through natural standards and technologies. 7.2 billion, i think. that coupled with investments with the tens of billions is starting to cause broadband by

wireless and i think it's definitely getting better. it's hard to get good maps of all that. we have done conferences on that issue as it relates to rural and much of it tends to be anecdotal. but the companies tend to know in the fcc is definitely working in that direction. many policies and programs are designed for exactly that issue. >> we also know the cable industry texas something like 90% of homes. and we have had no problem going anywhere, including the second highest mountain in virginia. within four months we had a very big top of that mountain and that was supported. so i urge you for those who are interested that has been a fabulous resource. >> this was also one of senator rockefeller's initiatives of the

telecom act of 1996, created the program and it was pretty ineffective for a lot of years. and it is much as they could administratively without an administration of the act because there hasn't been one since then to make it more effective so that more of that 400 million or so per year that gets collected in a few cents on your phone bill, so that it does get used for the program and the rural connectivity program. >> we have a question that i think everyone will want to weigh in on. i am certainly interested all of our panelists and what they have to say. ..

as. >> there is always some loser. >> 8 million miles worth. >> is a win-win to work on those issues for that very

reason for my part i have never met a member of congress on either side of the ideal and i have met a lot the did not think this was a good idea. they are there because of their political skills. not much could be said about him any other issue these days correct me if i am wrong, but this is one that is a no-brainer which causes us a nest in the field on the regulatory and legislative side. >> no losers. >> how disgustingly positive a way to end this discussion [laughter] this gives life to the idea

that with the alliance program on friday the 13th i think it is one of the bow slightly and important discussions we have had on any topic in a long time in a debit like to think our colleagues that will point to put this program together in the queue for the such a good audience into her help me to think my panel for one of the best of a long time speed -- [applause] [inaudible conversations]

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american writers national museum. national correspondent for the fort worth telegraming mcclatchy newspapers. washington bureau chief, chairman of the national press club bar committee. washington bureau reporter reporter, executive director for the national governors' association, the allison fitzgerald project manager for for initial news for the center of public integrity and chairwoman of the national press club speakers' committee thomas keeping our speaker and radu organize today's lunch, at its washington correspondent for the oklahoma and, the

heard on the hill columnist. mcmann the centennial professor of journalism and vice president of communications and marketing for the american counts on education -- council on education. [applause] our guest today on jay rates did come in 2011 became the first female governor of oklahoma dealing with her state being hit with deadly tornadoes in taking on additional responsibility as chairwoman of the national governors' association. serving two terms as a representative before coming the first republican as well as the first female lieutenant governor 1985 through 2007 in the second

woman elected to the u.s. congress representing the state's fifth congressional district 2007 through 2010. her mother and father both democrats both serve terms as mayor where she was raised. during her first year as governor she balances the budget while closing the $500 million deficit to lower the income tax rate. she also saw many priority signed into law including reform of which she calls frivolous lawsuits and education. this year she signed into law the income-tax cut and overhaul of the worker's compensation system. she has tangled with native american tribes over the decision not to extend tribal tobacco compacts also unsuccessfully to give communities more authority to regulate tobacco products in both parents died earlier

than they should have because of spoke -- smoking she is foster job growth in retention with work-force development as top priorities. she launched an initiative to increase the number of college graduates than career certificate holders to help the state attract and retain jobs. in august governor fallin name sheriff the national governors' association of bipartisan group with most of the nation's governors the focus of the initiative should come as no surprise. she says states in the businesses that drive the state economies can help secure their own economic future by aligning their educational institution and work-force training efforts with their projected demand of tomorrow's labor market. we will hear about her initiative plan for work-force development in her speech titled america works, education and

training for tomorrow's jobs. please give a warm and national press club welcome to oklahoma governor fallin. [applause] >> thank you so much change to let it is a great pleasure to be here at the national press club might appreciate the kind introduction and it is an honor to see my fellow oklahomans here today. i am surprised but before i begin my comments i just want to say how heartbroken we all are as americans and citizens about the terrible tragedy that occurred here yesterday in washington d.c. and the tremendous loss of life or thoughts and prayers in condolences go off -- go out and i know it will be a

difficult time for washington but we will keep you in in our prayers as you begin this healing process with the tragedy but in the meantime i am excited to be here at the national press club to join all of you and to seek my fellow oklahomans said with items to visit with you it was cited as the "face the nation" and also chris, a good to see you again. he used to cover me when i was in congress now he covers be a little bit as a governor it is great to see you. you have done a wonderful job over the years for our state covering the national news. it is always interesting appear. i am here to talk about an issue that i believe is

critical and important for the future of our nation's economy. developing a highly skilled, educated workforce and to close the skills gap between what employers need and what employees have. and august i have the opportunity to become the chair of the national governors' association. we work together to find common solutions in to identify the best practices so we can share with each other. we look at those solutions for those under facing our state. ours is to launch an initiative around a topic that is not only important to me but other governors across the nation.

i him with keen to establish a national dialogue between business, education and the public sector how we can best prepare students, and then and women to get good paying jobs and to keep pace sid to be competitive in a global economy. my initiative america works works, is about making significant improvements in education systems cover work-force training systems systems, and also to space those systems with the needs of our businesses and markets. it will also help the nation to reach shore american companies and jobs. governors i believe are uniquely positioned to foster stronger economic growth and especially that between our businesses and education system. the primary individuals that

are responsible for both public education and economic development in our state. those that dry state economies could help secure the economic future by aligning educational institutions with the projected demand of tomorrow's jobs. with the 21st work force is an issue that not only calls for national attention but i believe demands gubernatorial leadership. that starts with recognizing hard truth about the nation. navigating today's pathway remains more challenging than when my parents were growing up. but 50 years ago more than 75 percent of all the jobs in our economy required only

a high-school diploma or less to get a good wage job but today that number is dropped roughly a 40% and more than two-thirds will pay less than $25,000 per year. it is clear the high-school degree is no longer adequate to get a good job and access to the middle-class life. a post secondary degree or some type of career technology work certificate is the new minimum for economic success. for individual success and individual businesses to hire the workers that they need without a post secondary education they

will have difficulty to achieve the american dream to have a successful if a philly middle-class life and beyond. unfortunately we continue to fall short of this goal meaning we fall behind both as citizens as businesses too many high school students don't finish high school. nationally 78% make it to graduation those numbers are much worse for minority and also low-income students. too many go to college underprepared to take remedial courses often they will drop out of college and still acquire a lot of debt while not being able to acquire a college degree.

too many employers are saying they don't have the workers with the skill set that they need and colleges and universities are taking too long to create programs to help students about the high 80s skills set for today's jobs. all these are contributing factors in rally once led the world in student achievement we grab 14th in reading, a 17th in science and 25th in math in the industrialized appears section and all as a percentage of working adults means the associate degree in the united states mint one out of every eight people will now have an

associate excuse me refer for a first to eighth to have the associate degree in the workforce. we're just folly behind with too many students they cannot reach the middle class because they're not meeting the new minimum for the work force. we had the opportunity to visit with the ceo speaking at the u.s. manufacturing segment and he gave a great'' that says america has a training gap taking off those that need to be trained will never solve the problem and catheters are listening is set to the governor to build new pathways around the notion that post secondary education is a necessity.

today the fast-paced world where technology is ever changing, these pathways must be flexible and efficient and reflect the state's changing economic needs. vat to be developed with the employers, not just for the employers and most important they must be able to meet the students' needs themselves. for future economic security will require significant improvements to the work force training programs and also require closer working relationships with high schools, colleges, a career technology programs and also with employers. the challenge that we face is very clear. too few americans are participating in secondary

amid -- education and those are if not prepared to do so the first is we must get more students into higher economic standards by the end of their high-school diploma that means they are prepared for any form of post secondary education whether going on to college or a career technology school in without mediation. to successfully complete a degree or career technology program to pave the path it with the tangible data in the oklahoma i spent time and effort to use that to

identify the work force challenges to identify the specific solutions. we begin the process of collecting data to compare the demographics with the trends in the workforce needs we identify the current education level of our working gauge oklahomans then we watched the breakdown what is required for the jobs created between now and the year 2020. >> said data set of work force skills for example, 77% of the jobs to be filled by 2020 in the state of oklahoma is requiring in education beyond a high

school degree. only 54 percent fit into that criteria so that means a 23% point gap from what the work force needs to the educational attainment that we have. if that gap is not closed then we know our jobs will go elsewhere. with my initiative america works so states can work together to identify specific policies and strategies with the trading system to meet the needs and also to focus on five key elements to make progress.

>> the five elements are you have to have a state wide vision of for being able to close the gap between education and the economy. also to have the improved data system. with the public-private partnership to work together then to better align federal and state funding and other resources. let me take a moment to describe so what i hope to accomplish with these five key elements. first of all,, my papers are sticking together, i apologize. every governor has articulated his or her vision for education reform

and how they improve their economies. to make it easier for these governors between education and jobs too often in the data is not use to answer key questions are policy makers to help them improve the of the dole -- results. some things we have done and we know in oklahoma that we have five key topic of systems to generate the top paying jobs in the most wealth within our society and we go that aerospace and transportation in financial-services are the top jet walls generating jobs in ecosystems and the oklahoma. so we try to connect the dots between educational attainment in the types of

jobs that the employers need to fill. for the careers certificates they need to meet the jobs in the marketplace. in to identify the best practices to do that in to build a road map to take action. government alone cannot improve the education system and its realignment. the needs of our employers will need to be considered in be our partners with us. in to identify and develop the skills that also of the talent -- a talent. it to strengthen efforts in

this area and we all heard that einstein the definition emissivity is doing the same staying over andover expecting a different result. but the states will identify and share strategies to allocate and to better align our federal and state funding. finally will stop doing the same thing in pursuing the same policies and expecting a different result. it will help to identify problem areas built into the education system id with the closing of the gap between the skills sets needed from the skills of our employees have.

did with these five key elements we hope to leverage the great work that is already done rounder state in to share that information so we can all do better. . .