contribute his or her ideas. .. [cheers and applause] >> as people, by the way, we should be telling all of the members of congress, we just should tell them, every single one of them, tell them that. about 95% of the people in congress claim to be christians and i really use the word claim to. as people of faith we experience

firsthand results that unlimited has, whether immigration reform, fighting justice and the ability to have open and honest discussion on any of these issues. as shirtual people, we are called to create a beloved community and we are called to care for the poor and marginalized. the partisan divide in america is fueled by attack ads by interest groups who are unaccountable and unidentifiable . [cheers and applause] >> it's not one where wealthy voices are the only ones that are heard. the nature of the public common good should be focused on the needs of those most vulnerable in society.

as money begins to weigh more than our own voices and views, people see losing democracy. recent polls have shown that 80% of registered voters across all parties, believe that political system is corrupt and needs reform. [cheers and applause] >> pope francis in discussing the role of money, we created new idols and the image of money this is baseless and lacking humane goal. [applause] >> and so as the st. john, not to share one's good with the

poor is to rob them it's not our good to possess what's theirs. make sure voices of those in need are not ignored. our system of government, all it takes, though, is one good person, one person to restore, just one of us. money in politics is not just a political issue, it's a moral issue. pope francis calls for a bold cultural revolution. interesting take. he's been traveling around the world calling for that. let's be part of that revolution. let's begin that revolution today. thank you.

[cheers and applause] >> democracy protest just a couple of ways. we leave the scene to take you thrive capitol hill for a conversation about new ways to pay for medicare. the speakers organized by the alliance for health reform. >> i'm going to introduce our speakers. we have cristina bacuti, associate director of medicare policy and she's held a number of positions at hhs, medicare payment advisory commission and the government accountability office. next to her is marilyn moon, she's analyzed medicare program in various capacities, also

served as a public trusty for the social security and medicare trust funds in the 1990's. to my immediate right is patrick konway, medicare and medicaid services, and he's also the director of center for medicare and medicaid invasion, cmmi. you will hear that acronym a lot today. cmmi is approaches that we are going to be talking about today. eric young, next to me is trisha newman and her left is jerry young, director and cofounder of medstar medical center. eric will give us a glimpse and medstar expanding to other facilities. to my far right james, he leads

rochester payment program and has a hand in aco like and risk base models. so we are going to start off at the far end with cristina bakuti and talk about evidence that we have on hand. >> thank you, let's see. okay, good. so i'm going to start with just a little connect for delivery system reform and medicare. i am going to go a brief summary of three of the models and conclude with a few thoughts on ongoing challenges and opportunities. so to get right to context, i will mention a few items. although cms had been running a few models on reform. the affordable care act really brought in a large multiprong

effort to reform, created some permanent changes to the way hospitals are paid, for example, the hospital readmission reduction program. it created the office that medicare coordination office, looking at ways to align payments for people who are dually eligible for medicare and medicaid. and the aca also established aco's through what's called the medicare shared savings program, which will get into in a little bit, and the aca created the invasion center which, of course, cmmi because we love acronyms. cmmi was marking testing payment models and the aca gave it unprecedented authority to expand models that achieved

certain specified performance on quality and spending. i'd also mention that underlined system reform in medicare was the passage of macra, the law that repealed the fjr, many former alliance briefing topics, but macra has within it financial incentives for physicians to be paid a bit more. if they are participants in what's called alternative payment models and this will be coming in futures years. and so cms is planning to release some regulations in the near future, some proposed rules of what exactly will be used to to define the alternative payment model. that should be coming out soon. then a final piece of context is hhs's overarching goals to shift

more traditional medicare payments towards value instead of volume-based reimbursement, and perhaps dr. conway will be talking about that, so i'm not going to. but i will move on quickly to this slide which shows on the left-hand side three models of delivery system reforms that we cover that's in your handouts and i'm going to talk about some of the individual models that are on the right-hand side. so starting with medical homes, to distill it down, medical homes are really based on the concept that investing a bit more in comprehensive primary care could lead to lower overall spending due to better health outcomes when you invest earlier in primary care.

all three of the models on this slide here involve care management fees to the medical homes. and the first two specifically have a focus on coordinating medicare management fees with other insurers, private insurance and medicaid. and you can see on the map -- yeah. you can see on the map that they're clustered a bit for this reason. the lighter blue is mapcp model and that has more involvement with states. you can see then the whole state is colored in and then the orange dots represents the cpc participants and those models cmmi is playing a convening role with those insurers. the evaluation reports for the medical homes are starting to come in. i think at this time that

savings are not very high, but more results are coming. and the cpc model is showing some gains in quality but, again, the others are awaiting for results. i will move on just for a moment to the independents at home model which is also a primary care model, but, of course, we have an expert with direct experience, so i will just give you a couple of teasers that show what's unique about this model, and one is that it focuses on home visits to address the care needs of frail patients. a second unique feature of this primary care model is that it does not involve care management fees. in fact, has within it the opportunity for the independents at home practices to share in

savings if they've lowered spending. and then we will save early results from ip -- independent at homes with prominent savings. these are entities that have agreed to be held accountable for both spending and quality for the beneficiaries that have been assigned to them. they can contract with hospitals, physician groups, care facilities, the model that accounts for the most beneficiaries by in large are the mssp models. 8million beneficiary across over 400aco's. the mssp models with the most beneficiaries is the one that are called track 1 and in that model the providers don't take on financial risks with

medicare, but they can share in savings. there are new track that is are coming up but perhaps dr. conway would mention them so i won't . then there's also nine pioneer models which are required to take on financial risk. i say that about a quarter of the mssp's i just mentioned shared in savings as results came out for 2014 about half of the pioneers were able to share in savings, and that model did get certified to be expanded. then the last little model i want to note is the bundled payments model. i would just characterize this model on one that focuses on a whole episode of care rather

than payments made to individual providers for individual services that they themselves provide. the bpci demo has four different payment models that are triggered by a hospitalization but there are many details so i'm not really going to get into them, but to say that the results are very preliminary. so finally, i will just close with a few comments on ongoing challenges and opportunities. we see here that -- actually i have to put my glasses on. cms has launched -- to be fair a large number of payment models in a very short period of time in a changing healthcare environment. we can note that while we are all sitting here wanting results, congress, providers, cms for sure, it takes time and so there's certainly a tension

between what we want and letting these models be fully implemented as they're being tested. i say that the ability for cms to change these models while they're ongoing based on early results and based on unforeseen circumstances create great opportunities and great challenges for the evaluators certainly. a key consideration that cms and congress will be considering as results come in for these models is how medical beneficiaries are really fairing in these models and particularly those with high-healthcare needs. they're the ones that some of the models were designed to help. let's learn about them in particular. thank you. >> thank you, cristina, that's actually a great transition because marilyn moon is going to talk about how consumers are

fairing under these models. marilyn. >> thank you, i'm going to be relatively brief because i may be talking about a one-horse pony here idea and that is that consumers matter and you really need to take them into account in these kinds of models. some of the earliest innovations that occurred and some of the earliest thoughts about innovations were done without even thinking very much about consumers. imagine anded aco that's getting organized in the accountable care organization that is thinking about steering patients into different -- different other providers and slightly different models and approaches, but the beneficiary of it has no idea that they're in aco. they may or may not have gotten a letter or may may have known and in many cases they're not quite sure why the physician is doing that. if it is for good purposes for

both improved quality of care and lower prices, that's all for the better, but you're going to get a lot better cooperation, a lot better engagement and involvement if the beneficiary actually is engaged and knowledgeable about that. i remember when people were talking in an early event i went to about medical homes which you would think would be particularly consumer sensitive and people were talking about patient center care and going on and on and after mentioning patient-center care, the term patient never arose again in the rest of the conversation including when someone was asked about it, the individual said, well, as a physicians have the patient's best interest at heart therefore they can take care of that problem. i think we need to change every one's minds in the healthcare world. you are not going to change the

healthcare system if you have patient that is are resistant to the change. none of us like to change things that we have become familiar with and comfortable with specially something as complicated and uncomfortable and important as health care. so it's very important to get people on the same page. air where i work did a study a number of years that i wasn't involved but i thought was fascinating where first they interviewed patients and then they interviewed doctors and gave them the exact specific scenarios about health care, trying to get people interested in quality, and what they found the reaction of the patients and the physicians were totally different. the patients' reaions when they were being encouraged to deliver a baby, what would i do that, i would just ask my neighbor. in the case of the physician,

why would do i that, why would i even want to take a patient because he is or she are going to be latigous. they were not only a resistent to quality but they were on a different page. so there's a lot of education and activity that needs to go on. now, i will note that as mentioned the new generation of models that are coming out are getting much better at that. they're trying to find better ways to involve patients. it's important to keep in mind that this may be a little dated but still something to keep in mind because it's easy when people get focused on all the tough technical things to do to leave the consumer out of it. one of the important pieces that needs to be part of all of this is to ask the question what do patients really want to achieve and when designing goals, for

example, for complex care, let's say postacute care, it's very important to know what the patient wants to achieve. i can give you a personal example when my husband was first out of the hospital and on home health after a stroke where he couldn't read numbers and he was very confused about a lot of things, he had a they werist -- therapist that insisted he needed to how dial a telephone. nonetheless, she was down and determined that he was going to dial the telephone and after five sessions we essentially told her that she needed to come back. she never asked him what he we wanted to achieve and there were plenty of things that she could have achieved rather than the frustrations that he went through. so whether it be to climb a set

of stairs to sleep in their own bed, if you have health problems , they have a goal in getting them early on is very important. finally it's important that it's an opportunity to build in consumer issues from the very start to make sure that gets baked into a new healthcare system rather than add it on at the last minute. it takes time to achieve savings because everybody is adjusting to a new environment. and before we either give up on new innovation or before we say that they aren't working, we have to make sure that everybody who is involved, physicians, other providers and the patients, are all on board before we judge whether or not it's been successful. thank you. >> great, patrick. >> so thanks for having me here today. i really appreciate it.

thanks for allowing me to be two minutes late. i apologize. i was coming from another speaking engagement. so actually a great segue, i think the reason we do this work is the people and the patients and families we serve. i will hit on some highlights but at its core, we think we can have a system that achieves better health, smarter spending and healthier people and to get their i do patients and families have been at the center of care. we have policy principles we use at cms. one is patients and families first. one of the things we alluded to. the president and the secretary announced in early 2015 that we wanted to move at least 30% of payments by the end of 2016 and payment models for quality and total cost care such as aco or bundled payment by the end of 2016 and then march we announced

to reach the goal ahead of schedule, approximately a year ahead of schedule and i will -- and that really is a fairly dramatic shift in the delivery system. a lot more to work on what works, and why, and what is scalable and expandable but a major shift on how we think about paying for care. goal number two includes things like hospital value base purchasing and tied payment to quality and/or costs and medical linked to quality and cost. we reached that goal ahead as well. it's not a medicaid issue, it's medicare, et cetera, we launched the healthcare payment network to try to collaborate across the public and private sector to not only aleave the goals but better care on behalf of patients. we got eight of the ten largest private payers in the network.

we have over a thousand providers, consumer and patient organizations. large em -- employers and agree on how to report on and maybe most importantly work on alignment on many of the models. if we are talking about an aco, can we agree around basic constructs around quality measures or atranscribeution models or how patients might do voluntary atranscribeution. we are doing that work now. this is long-term journey. the number of the folks around the table say think worked, one of the most meaningful public-private partnership they have done in a very long time. that is the goal to do in this partnership.

we chose a lot of the same models to highlight. aco model as we said, almost 480aco's serving about 9, almost 9 million beneficiaries now. we do have increasing numbers now in risk-bearing arrangements. 54,000 and counting. you are seeing in public sector. improved quality and lowered costs certified by the actuary. pioneer was designed to organizations can exit but nobody could enter by definition. your numbers go down over time. so our model is much more flexible construct where people can come in or out in a much more flexible way.

we are going to have a couple of years of adding aco's. the first year was application cycle. they have opportunities to exit and others that have opportunities to enter. a few key points, one patient can voluntary say this is my aco, this is my choice and then they're in the attributeable population and staying in network. it rewards quality. it waivers around telehealth and providers ready to partner with communities to move to a much more advanced, this can be a fully population statement, totally moving away from people service. we are excited about this model. applications are open now for new participants. primary care, i have update as of 10:00 a.m. this morning, so

this was our first model on this slide that did show decrease hospitalizations do -- we are going to release next set soon. it's got two tracks andly talk more about those. estimated 20 states and regions. multipayer where we agree on quality issues and basic approach. could be 20,000 physicians in the model and 25 million patients. so it is the largest primary care model in u.s. history. and we think very exciting, track 1 is similar to cbc but has a couple important changes like having the financial incentives at the practice level and more reapplying to practices on a monthly basis. track 2, they can move to

population-base payments. greater than 50% of payments come from population-base payments and and reduction in fee for service. really opens up that practices can deliver care the way they want to and patients can receive care when and when they want to. sorry to talk about that one a little longer, but exciting, just in time delivery from this morning. independents at home i'm going to let other talks about. ly let others that know the model better than i speak to that. bundled payment, which you will hear more about. we've got over 1500 episode initiators, physician groups, hospitals, taking on two-sided risks in 48, one or more episodes, these are things everything from surgical conditions like hip and knee replacement, we are redesigning the care system. building those connections

between hospitals and providers and we are actually working on releasing some more results here as well. that led to our comprehensive care for joint replacement model which in 67 markets we are saying, we are testing. we want you to improve quality and lower cost and better coordination. it actually includes patient reported outcome measures. directly hearing from patients about their functional status and outcomes, which we think is incredibly exciting. we think an exciting development, i will end on time, i have 20 seconds, i will say a few more sentences. i'm still a practicing physician. this is exciting work. i think we have made significant progress over the last three to five years in improving the health system. collectively, we have to view this as a long-term journey.

i always want short-term results as well, but we need to continue to evaluate to learn in rapid cycle, to scale what works and i think -- i look forward for the rest of the panel and discussion but exciting times. >> fantastic, thank you, patrick. this is the part of the program where we turn to the on-the-ground perspective and we are lucky to have with us today two gentlemen who are right in the middle of these experiments, and so we are going to hear from them. before we do that, though, i want to remind anybody who is following us on twitter that our hashtag is medicare demos. after the eric and jim speak, we are going to turn to a q&a session. for those in the room you have two options. there are two microphones in the room. you are welcome to ask your question at the microphone. you also have green cards in

your folder that you can write a question on and our staff will be around to pick it up, so we have two more presentations before we get to the q&a, so get your questions ready, if you want to start writing questions, feel free to go ahead and do so. if you are watching at home on c-span, you can tweet us your questions. we do take twitter questions and we will try to answer as many as we can. again, hashtag is medicare demos. i am going to turn it over to eric young that is going to talk about house calls. >> thank you. thank you, can you hear me? thank you very much. i'm going to start off with a disclosure which is on my front slide. we are talking about home-base

primary care, care for frail elders and how that has lead to ih independence model that has been quite successful in results announced so far. my disclosure is at the bottom of my slide. it's my responsibility and there's no review or verification by them, although, hopefully patrick will be okay with it. next slide. i'm going to talk first about the patients that we serve. i would like to do a brief survey of the room and how many people in this room have an elder in their life who is sick and has trouble getting to the doctor's office? just raise your hand. all right, looks like more than half of the room. independents at home and home-base primary care is the model of care for those people. 17 years ago dr. george came to dc and zieted to set up a clinical model of care for those folks who are sick elders and frail and have trouble getting

to the office. essentially a house-call but more than that that would follow them across all settings. we will talk more about the details of the model. we then wanted to look at the effect of the model, a mobile base approach to care in the home on quality of care, the patient's experience and ultimately the cost of care, which is i would say a secondary outcome, most importantly, what is the impact on the patient and the family. and i want to talk about what is next, help us expand the program. so who are the patients? it's actually a highly-targeted clinical service. in contrast to some of the other demos it targets less than 5% of the medicare population.

in our practice, they age 66 to 110, 110-year-olds recently passed and john january 1st, 1900, at the beginning of the century. this is the kind of folks that we take care of. the service, intervention is really simple to describe but hard to execute and disciplinary mobile primary care teams. 24/7 availability across all clinical settings. it's not just about making house calls. you take care of the patients wherever they are and coordinate all services that they need, medical services, social services, subspecialty, transportation, whatever they need. the goal is to enhance the dignity of elders and bring peace of mind to caregivers and families. those are the goals. it has dramatic impact on per capita medical cost, which we will talk about in a positive way.

the independents at home model which was based on home-based primary care systems across the country allows home base primary care teams to be scalable. that's a major take-home point of the day. the independents at home both demo and payment model allow it to be scalable. the reason for that -- we will talk about more. these are the main points. there's very strict criteria for eligible patients. you have to be frail, disabled, have had high costs in the past year and there's the high bar for service quality in the program. you need to have all the researches in place to really take care of good complex patients. you only receive savings, only after you've achieved 5% reduction and per capita medicare costs. there's no up front payment to these programs and there's no payment until you've exceeded statistically greater than 5% reduction. you have to link the savings to six relevant quality metrics,

the providers would get 80% of savings beyond that first 5% if they meet all six quality metrics. this highlights, this is a cbo study, highlight it is focus on the top 5%, why that has such a big impact. the orange at the top on the left is the number of beneficiaries but they expend nearly 50% of the budget and this is similar now in the current medicare and medicaid population. i'm going to talk about a patient briefly. this is a 69-year-old who had liver and heart failure falls and a lot of burden. she had six admissions to the hospital. six admissions per patient year in how services speak. the daughter moved the mom to dc zip code in order to get entry to ih program. for the last four years, she's received over 150 house calls,

many social services coordination of aids, a lot of home x-rays, many urgent visits by our team, terminal diagnosis of liver cancer reversed by subspecialty care. she was having massive hemorrhage internally and thought she was going to die and we use it had hospital high-level, high-tech care and she's been home again for the last 18 months. in the last four and a half years now she's had two admissions, .5 admissions per patient year. she's been four years older and four years sicker but not been in the hospital more than twice. she had one er visit in four years. i have to change this, just two days ago she had an er visit. so how does this work? this is a busy slide. i won't read it all other than to say the home-base primary team has to coordinate everything.

it's a direct team of people coordinating everything the patient and family needs over time until the last day of life. we coordinate routine and urgent visits, today from the weekend we had ten unstable patients and there's nurse practitioners all around dc making house calls and keep people at home. we coordinate er care, subspecialty, we direct ourselves. we are available 24/7 as most of the programs have to have a 24/7 availability. the next six bullets are just all the things you can do at home. what is really possible? the hospital really is only for intensive care, surgery, procedures, complex-level of things, you do almost everything at home from radiology to blood draws, equipment, iv, therapy, iv fluids. as long as you coordinate services you can have dramatic

reduce in cost. restored her faith in the system and gave them encouragement support every day and the good days and hours she are as a result of passion and commitment of those who create it had program and she gave us permission to give this quote. va study, 12% lower costs, the study of our program in 2014 showed similar mortality but 17% reduction and the independents at home, 20% per capita cost reduction, a thousand dollars per patient month. close to $12,000 per patient year. nine of the 17 programs were paid savings, then year 1, 25 million were saved in about 12 million returned to the providers. i'm going to close with just what are the challenges going forward.

finding the skill workforce is probably the number one goal. it's very doable, the people are out there but you have to have a financial model that will support them. you have to build a lot of practice capacity to support these teams. all the other service partners and have a commitment for value-base care. unfortunately medstar health is building a new team in baltimore based on independents at home results and both the quality and cost savings because they have faith that other payers will reward this kind of care o. how can you all in this room help, we are working currently with senate finance, house ways and means to turn ih into a national program, permanent part of medicare available in all 50 states and dc. i'm glad to talk to you in q&a about how that is going or afterwards. people who are in the last

couple years of life, their sugar level doesn't matter that much when they have a year or two left of life. it has to be within parameters. cms to great credit has been working hard on independents at home to target the right patient who is have persistent high costs, use fair and rigorous criteria for new practices as we roll this out across the country that will preserve the quality and the impact and then use really good fully risk adjusted methods so the results are fair to both the government and to the provider. here is a picture of our team. this is the most important thing that we do, that we have every day. this is a team of 20 people who are here in dc who do this work and finding the right people is the key to success. thank you. [applause] >> i just have to say that i have the privilege of sitting in on a team meeting and shadowing george tyler who is your partner

in crime and this is -- this is the work you kind of hear about. this is team-based approach. it's collaborative and using people to do what they do best in different capacities and if i had someone who was old and sick and impaired in dc, i would be thrill today give -- thrilled to give you a call. >> thank you. >> they are trying out bundled payments. jim. >> great, thank you. i appreciate the time to to be here this morning or this afternoon. i do want to just level set understanding of what bundle payments are. in simplest terms are a single budget ff an episode of care. we had a little bit of definition around that. it starts within our case impatient admission and what we call anchor admission and goes

beyond this charge out to in our case 90 days, there are options for less time than that and includes really everything that happens to the patient after they are discharged from the hospital, in-patient, outpatient physician, those kinds of things. the term that was used earlier that marilyn said that the patient comes first. when you think about a patient center i think first and foremost about bundles if somebody has knee replacement surgery, if i have knee replacement surgery, i think bundles starts when i go to my doctor and i say, you know what, the injections aren't working anymore, the medication isn't working and it ends when i get to go back to golfing and how i have a better excuse for how bad i golf. but that's the totality for me, that's the concept of what knee replacement is and that's how patients think about it.

it's not the way we deliver it and finance it and not how we pay for it. i'm very excited to be part of this program because i think it very much a much more patient centered viewpoint. if we are at risk for the care, there's a huge incentive reduce unnecessary care and reduce unwarranted variations. that's what we started with. we started do we have volumes here that would indicate that it's worth doing and do we have variations that would say that there is something that we can do to reduce that variation standardized care, improve care and reduce cost. but while this is a financial arrangement and a contracting arrangement and that's why i'm involved, ultimately first and foremost this is a clinical practice. it is a clinical program and so we had to go to them, we took the data which was all great and we went to the leads of our service lines and said, here, here are some opportunities, here are potential opportunities

for us to improve care and reduce cost and dip our toe into value-based payment. what would you do differently? what would you do to go after this opportunity? what resources would you need? how quickly could you get there? and that really then -- not only did it give us we can get this done, we had the clinical knowledge to get this done but ultimately do we have the clinical leadership to get it there. this brought us then down to major knee replacement as one opportunity and then congestive heart failure as the other. those are very different programs. so this is just a little bit of the data that we have started with. this is our baseline data of some of it and each vertical line is an episode and the colors indicate where the dollars are being spent. it doesn't take a rocket scientist to take, gee, green is

where we need to focus. and we said, you know, we can probably do better than that. we can get it down to 25% within a year. congestive heart failure completely different story. i look at that and i go, what red and how can we eliminate it and red is readmissions. the whole thing about congestive heart failure is keeping people from coming back. if any of you have anybody in your life that has congestive heart failure you know the constant revolving door. all right, so we've nailed what the objectives are. now we have to have a plan to get there. we start, of course with the f -- in-patient side. so we actually brought the postacute folks into the facility and said, look, work with us, help us understand these patients, help us figure out not only what we do here but also what you do on the post

acute side and let's coordinate and have a unified plan of care across this continuum and once we figure that out, we need a way to keep track of those folks across that continue uim. we have a couple of resources. one is a dash board, a place to put people, a software package and we can keep track of people. but the real key is the care navigator. one person that has specific focus and responsibility to watch these folks across the continue of care, here you go, but it's continuing that process all the way through the end so that a single point of contact both for patients and providers. the other major resource is in-home care. it was getting rehab done at home, for con congestive heart failure, totally different approach. home care resources in a rapid

environment so that instead of picking up the phone and calling for an ambulance and going to ed and back to the hospital, you call the nurse navigator or the nurse visiting nurse service and say, come out and do an assessment and they can actually bring telemedicine resources so we can do consult with cardiology on site. so results, we all care about results. this is major joint replacement. 74% at baseline. we set a target for 25%. we have blown through that. that's not enough. we want to make sure that we are not doing that and people are coming back to ed or maybegettie they need. our ed visit rate actually went down. not only did it not go up, the ed rate went down. we are very encouraged by that. we did the cost curve. we did achieve what we were

looking for. we think we can do better. congestive heart failure, completely different population. we have not yet really solved the readmission problem but there's one shining star on this. remember, we had clinically pathway and part of that was home care, enhanced home care and is if we look at just the population that went home, the people that went home with no home care, they refused it, they came back at least 47% of the time they came back at least once. if they went home with home care agency, they came back 43% of the time. if they went to home care agency committed to apply rapid resources and doing telemedicine and iv medication we use to control fluid retention, 17% of the time they came back. so there's a glimmer of hope

here and i think if we just keep focusing on that model, i think we will do better. and i just want to -- in the 30 seconds i have left i want to say there's one piece of this that i'm really excited about and sort of the spillover effects and the lessons learned, and that is you would expect the clinical leaders would all be about, let's apply these resources, great resources to more than just medicare bundled payment folks, and so we've had that. we expect that. what i didn't expect is just as much attention from the administration of the hospital saying how can releverage this to other patients. we have a unique opportunity here to really improve the quality of care that we are delivering, reduce the cost that we are delivering, how can we figure out a way to afford this to broaden it up to other populations. that's a really exciting place for a policy like me to be because usually you're trying to drag along the culture and instead i'm seeing the culture

change before our eyes. so i will end with that and we will take questions. >> great, thank you for the very, very specific information about these on-the-ground programs. that's incredibly helpful. we are now open for questions. i invite folks who are in the room to come up to the microphone. i would invite everybody who prefer bring a question in the green card. if you are at home watching us live on c-span, please tweet the question, anybody the room can also tweet a question. again, #medicaredeoms. while we are getting folks set with questions, i will turn it over the trisha to kick us off. >> this is the question for patrick, we did some work a few years ago that looked at people who live in nursing homes, so people on medicare who have very high rates of emergency room use.

they go in and out of the hospital, they're high medicare spenders even though medicare is spending for nursing home residents. i think there's two demonstrations. a new one and an older one. can you tell us how they're moving and what the evidence might be? >> yeah, there are two. they're both managed by the innovation center in our office that was alluded to folks on beneficiaries and medicaid and medicare. the first was evidence-based practices and implementing those, we did see early evidence of decrease of admissions and readmissions and higher quality, but early in that program. then we overlaid a financial incentive on top of that model. so to really reward financially as well, if we were able to prevent admissions and readmissions. this is a population that we care about deeply and two models that have not been certified for

expansion yet, but the early results are promising. >> great. >> i'm dr. carolyn, i'm a primary care physician, i have a specific question for dijon. specific question is home health visits. my understanding is that congress has been cutting amount of money for home health because they think there's a lot of fraud in the program. the fraud that i have seen because i'm also an attorney is for profit home healthcare provided to people who don't need while avoid it for people who do need it because it's expensive. my question for the panel is along the lines of marilyn moon is value for whom? i know value is supposed to be quality over cost, but who --

are the patients involved in the quality measures? and i don't mean patient satisfaction surveys because for healthy patient that's parking and ability to schedule and to call the doctor at night and for a sick person, it's time with the doctor to ask all the questions and get the explanations and get some empathy. >> yeah, two questions there. one is about home health care, the medical house call caps into skilled home health care as needed. we have found ethical agencies that we work with and we use them when we need them for episodes of care but they are part of the team in the ih model, and then, you know, in terms of -- could you restate your second question? >> the second question has to do

with value, when we talk about substituting value for volume, i guess you're talking about quality over costs, but value to whom? >> my perspective independents at home look at this as well, value to the patient and family in terms of their goals, their outcomes. in fact, one of the six metrics at home that's directly linked to savings is where the patients and families' goals are documented whr they receive a house wall within 48 hours of going home. value for the patient and family first, and then value for the payer in terms of being able to afford the care. i think it has to be both. >> but i would like to hear dr. conway address it or some of the other people that are involved in the program setting them up, setting the quality measures, whether patients are involved in the quality measures. frankly i don't care how many mammograms my doctor has ordered. >> i think you're making a good

point. i think what makes more sense to me is to think about whether or not there's actually both flexibility and coordination that goes on because then you are talking to the patients and you are getting involved in what the patient wants and it seems to me that in terms of achieving those goals the kinds of things that we were hearing about both in terms of the bundle payment and the independents at home have a better opportunity to do that than the ones focused on -- more technically focused and don't involve the patients as much. >> and we do have patients on the various quality development teams and committees that review quality measures for implementation in various programs. that is critical. >> so let's move to the other side here, if you could please identify yourself. >> hi, i'm joanne from institute center for elder care and advance illness. i'm delighted that we are on this journey. i feel like we are sort of first

winter, knowing where they are headed so far but having no idea how far away it is and what they will encounter. but i think that really continuing to work on what it is we are trying to get to is an important part of the endeavor because some of what we are now doing may make it harder to get to where we hope to go, and in that light, let me invite folks to weigh in some of where it is where going. we talk about total cost of care as if that's an obvious idea. we are talking about total cost of care in medicare. the big issue is long-term services and supports and specially family caregivers, so let me cut all those sniff days and we are terribly proud of it. we forget that means that some families have to take patients home unable to do a two-person

transfer and someone has to cope with that, someone losing work, the caregiver, the average woman family caregiver loses a quarter million dollars by taking care of her mother. that's -- that's big, but we don't account for that. the big issue is not -- i mean, it's a big enough issue just what we are going to do within medicare, but medicare has a huge kind of barrier and it's even bigger specially to start counting family care giving, and if we start counting care in that arena, not wanting to be a burden on kids and grandkids. some real end point not just paying providers, eric and george started their effort 20

years ago. we knew then what we needed to do, it seems that we really have to start kind of planning these modifications in light of where we hope to get to, and that requires thinking in terms of small localities at least for the very sick people. it doesn't matter -- >> do you have -- are you going to a question? >> yes. i want them to weigh in onto where this is going. >> okay, that's -- >> one of the directions for movement would be to really take account to the seriously disabled, seriously frailed elders and build there and much of what we are doing makes it harder to do because we are building financing quality measure line that does not support that endeavor. >> let's see if we can get a reaction from the panel here. anybody? >> i can take a little bit of that.

you bring up a really good point and deserves a lot more than i have the time to address today, but let me just give you a small sliver of what we are doing. so we don't simply turn people over to their home and say, here you go, good luck to you. it actually starts well before the surgery when we are talking about joint replacement, with go out to the home and meet with the caregiver and plan discharge jointly so it is not our decision to say, you are going to go home, it's a joint decision with the patient and their caregiver and -- and the providers. so you're absolutely right. we can't just people home and expect that the family is going to pick up the slack. >> great, let's move to the other mic here. did you have a comment, patrick? >> we are trying transformation

work to start to address more of these issues and the holistic care paradigm and testing at community levels to improve health and health outcomes. i think it's a fair point that we have more learning to do in this what arena about how to do this the best way possible. ..

to really listen to you. is your variance? >> to have the conversation around improving care and they understand the value of care. dr. conway, i want to first and foremost applaud you for all you've done today to demonstrate how important collaborations are from the very beginning. our organization is funded as an alignment network specifically to facilitate collaborations in meaningful partners of patients and families in the medical redesign. dr. conway, i want to have a talk about bad some of your learnings and how cms is starting to evolve those relationships and even through the expansion of broker that are successful in their programs you are developing, what are you doing to better assure they are in collaboration with meaningful

partners in the very beginning. >> thank you or the question. it's a critically important issue. a few things we are trying to do. one is talking about the quality measures and the quality focus we think patients and caregivers are the most important voice in that equation. we are doing this now and i appreciate the positive comments. we need to do it better. how do you engage patients and families in the design as you said and the life model. this is something we've met with a number of groups and how to do it more systematically. stay tuned for more, but we agree with the com that the iraq patient, people, consumers and families and caregivers to be inclusive of baath ball to help the siamese models, to be co-creators both at the start through the evolution of the

model as we try to improve models and aspects of the evaluation of quality measures. >> thank you. let's move to a question from one of our green cards. we have a few questions on the issue of how to follow this in rural areas. several of the dumbest rations we've heard well suited for areas where there's a concentration concentration of people and providers. there's a story the paper this morning about the challenges that people in rural areas face comments initially people on medicare and living in areas. this is for anybody on the panel. we talked about scaling things that were. do they work in rural areas? >> this is eric deyoung. independent that home can work in every state in the country. rural, suburban and urban. the challenge will be how do you staff in arizona and new mexico miss an iah homebase primary

care program that uses mortality of, slightly different staffing. the doctors are some thing can achieve the same goals of using mobile to knowledge he with a slightly different staffing. this can be done in any geography. >> this is an issue we focus on significantly. the primary care models can be done in rural areas. we did advance payments and other matters which in our acl program had the vast majority in the last round to participate in first all practices are rural practices to help with the transformation work. we are also engaging with the number of states thinking about population-based payment for rural areas and what that might look like. more work to be done by the number of models can work successfully in rural areas and how to make that even more

common. >> my name is jenny boyer with the help of federal services. where the contractor that manages the east. >> pull the microphone a little bit closer. >> share period russian to those of you involved in making a peer of the pilots are great when it's well known in high-quality delegates for a small area. how do you scale that and what happens when the quality inevitably deteriorates? >> so if you thought. one, the majority of our pilot are voluntary either community state or provider pilot. you are seen in number now like

the joint replacement which are testing including all providers in a geographic area. the sequence there was we saw early positive results in the tree replacement model from the bundles model is talked about. now you test a geographic area to learn what you just described. will the result be the same in a diversity of providers. we do have monitoring train to minimize unintended consequence is and we have monitoring, the ability to pull people out of models. other tools we use when we have major issues. you need at a rate testing strategies. you pick up the early years and now i'm in the big metal and are shifting the curve as was alluded to. how do we now learn in the big metal transformation that what works with the big metal if you will, sorry to answer long way. good question, though.

contacts that providers matter, if better appeared we are trying to structure this in a stepwise progression that picks up an increasing number of states, communities and providers across the country, including one that weren't high performers to want to be high performers. lastly, sorry, supporting people. we are making major investments are transferred to clinical practice alluded to other initiatives to support various providers, states and communities. >> maryland, could i just add that not only do you see in the beginning a high performers, but you often see the highly motivated and ready to change folks. it is the not so ready to change people that you are worried about ringing these two. i'm glad to see dr. conway talking about the importance of providing resources and education and information to people because the leaders

already are motivated to change in many cases. it is the folks who are just not sure that's what they want to do are skeptical any to bring along and that is the next stage of all of this. >> thank you very much. another question at the microphone. >> the long-haired discussion group. i've really enjoyed the presentation about the independent and home program and the savings to medicare and the quality of care. i thought of this question before the other two questions. it is sort of a follow-up. what do we really know about the incidence of long-term care, medicaid cut and the burden of unpaid caregiving. if you don't have specific studies, what is your sense? does it save in assisted-living nurse in the hall and home care services or designate and what

about the need, the poll in the unpaid caregiver. >> thank you. in our visit in d.c. we have a less than 5% and defensive nursing home placement per year. 95% of her patients stay at home on their and that is much lower than the benchmark around the country for this population. we haven't done the medicaid analysis here there's a number at 10 and within cms an interest in doing that. our experiences social workers on the team as we do in the true interdisciplinary approach and get the care for the caregivers in the patient in place. the kind of amount of nursing home placement and therefore medicate caused me to get way less. >> i'm afraid this one might be for dr. conway, too.

anybody else want to join in would be terrific. everyone including presidential candidates is talking lately about the problem of rising drug costs. how do these demos address the problem and are there any particular dumbest that directly address the issue and i think i know from where you are speaking this morning that you have a specific demonstration to talk about. >> a number of the models to include drug costs, typically be caused that next-generation is the possibility of organizations bringing in the costs. arcology care model we look forward to announce being the participants include anp costs, drugs. we have a part b model that directly focus is on paid value and better patient outcomes and part b clearly does not limit

access. we do not believe the proposal limits access for any patient to get a major they need in any position to prescribe any drug they think is warranted. if there are examples people can provide around a mac says, we want to know about those because the access and better patient outcomes is a core principle for us. the part b model is a proposal that we seek comment on that could directly be aligned with paid for value of the drug arena. >> with another question at the microphone. >> this is christine grossman with the alliance for specialty medicine. i actually had a question for june. i used to work at cms until quite recently. i had a question on your bundled payment portion. you talk about the care lasting until 90 days pose services. i wanted to know -- i've heard

several talks both now and in my decision in the past at cms having issues and turned the following not with patients in getting information past 90 days. i want to see if you all account for that and what you do in terms of this to follow-up and how that goes and the bundles care. >> patient while it is a huge issue for us, particularly for the congestive heart failure. i will tell you a little bit of a story and this is only tongue-in-cheek. one of the medical directors of the congestive heart failure program said if he could find a way to combine the oral lasix medication, which is the drug were used then we could get our patients to be compliant. and he was only half kidding. when you talk about patient

follow-up, we have care navigators that are constantly calling and visiting folks to try and get them to come into those follow-ups. one of the reasons we have initiated till health services. so if they can get back to the clinic for their follow-up appointment, we will go to them go to bed to have to visit wherever they have to be. the patient follow-up is one of the hardest things to do in this population. >> okay, thank you. to follow at night let's talk about additional implications for involvement. there's pros and cons associated with passive enrollment. so what are the implications of more or less patient, beneficiary involvement.

>> i can complement or as an analyst looking at a pros and cons. while some models are being introduced in the future that allow more patient engagement, the ones we have results about to have more of the passive that should be. i think some of the thoughts behind not by that and the one hand it's not very disrupt it to the patients. this is going behind the scene through claims-based analysis. and it in fact places a greater role for the providers to engage the patient and work on the care. and it eliminates some of the election issues although it's more of the patient election whether they'd be recruited or not recruited. some of the enrollment from an

analyst is customary. on the other hand, you are losing baghdad's passive attribution. you are losing patience volunteering to be part of this model and then being worked react to and listening to the care decisions and making choices about which providers might be higher-quality lower costs. i think there is a push and pull. i imagine that the future model coming are going to be addressing both a push and pull about collection issues versus patient engagement and patient involvement. >> for some it could be both. there is both passive populations plus active choice population on top. we do want to learn how to do

this best and what is the deepest level of patient engagement necessary. just to build on the answer to agree with, some models may be both. >> i want to know we have 15 minutes or so to get through more questions. i want to point out in your package you have a blue evaluation sheet and would be very grateful if you take a moment to fill it out. we've already made it a little bit shorter so it easier to sell out. this is not an invitation to leave. so i would actually like to ask patrick and the others into the future into the next year to give us an idea of what is coming next, whether the expansion of of the programs already seen in the demonstration projects whether

we are expected to see some new kind of programs bubbling up that aren't necessarily part of the demos, but they are starting to come about in the private sector. what will be the focus? what do you all see down the road as we look ahead? >> i'll start on this than others. great question. first i actually see the level of transformation accelerating and my prediction in a positive direction. i see a cultural shift. three or four years ago attacked a big group ceos and i could tell that may happen someday, but not that worried about it including tangible example where they'll never be in the models another in a bunch of models. i think using a cultural shift that people know this is where they are going. the path we are on to get there. the progress will continue

regardless if it is truly bipartisan. on the details they call it remained things. we announce certification of the diabetes prevention program which we haven't talked about today. a few weeks ago you'll see increasing results for expansion and therefore expanded program. you'll see us take learning programs propose them into various programs. i think you will see continued that fill gaps like primary care model today working on direct number models that are hard to get right but we are working on health plan innovation. its proposal pa three, this private sector public partnership aspect you will see accelerating. increasingly when i interact with private payers there's agreement on this is where we need to go. there's agreement on the

high-level payment models. i think you'll see a shift across public and private sector which had to do with much easier to succeed across your payers, et cetera >> i'm talking about how will this affect things. the argument for increasing impetus for change comes from the demographics of the baby boom population turning 65. much more accustomed to questioning authority, much more accustomed to being skipped the goal about being told something by a physician, for exceeding old. with all of the attention and publicity around change, recognizing the change is not only going to be coming, but

people want to have a role in if they need to be fairly active. on the passive side were the more troubling side, we have been increasing population of diverse people than we do now is increasingly the number of latinos and african-americans increased as a share of the population on medicare. the increased diversity means you have a bit more of challenge in reaching out to people with different cultural backgrounds, particularly on the hispanic side where we know from a lot of race urged that people behave differently, respond differently, interact with health care providers differently and unless we reach out and try to provide good education that there will be some problems there. it will be on the one hand, on the other hand.

there will be some positive things that needs to be done. >> i feel like it's come up here on the panel which is workforce. i see that changing the bit where we have the navigator with the bundling and we have community health workers in boston hospitals in the paper today. the rural areas they came up as a question. different workforce models that may have the ability to coordinate care across settings even better. if the payment incentives continue to find ways to marry those into the workforce. that needs to be cultured. there's other systems to develop

that. >> i have a question which is we are talking about changes in traditional medicare and really observing from different models in order to improve the way care is provided. i am wondering how all this relates to what is going into the medicare advantage world and whether or not the lessons learned from medicare advantage are being applied into traditional medicare and conversely the things that are working in traditional medicare being injected into the medicare advantage space and halliday beneficiary now. >> i will start. others can jump in. we are having this bidirectional binding and approaches that i will describe briefly further. there's an example of insurance design which was launched in medicare advantage. we had been much of that work for the private arcade.

it is bringing the learning and testing them in the medicare advantage network. i interact routinely as do many of us with the medicare advantage, various clinical quality and leaders. we learn from him on the work they do as well. likewise bundles, independence at home, primary care, other payers encouraging them. often we can encourage but not required, which is appropriate. encouraging the various medicare advantage plans to adopt or consider adopting new payment models and we see that happening. you will see the way the pants pay providers and traditional providers increasingly converge over time. >> just as a quick follow-up, for something like independence at home focus on people living in the community, as that's

something that is part of the care system medicare advantage plans are providing as far as you know in the cms working with medicare advantage plans to be sure the best practices if they are best practices are being replicated no matter which delivery system they choose. >> can i mention companies are taking up independence at home and there's multiple states of new york and oregon already programs having contracts with companies to bid under per member per month that covers the cost of the program. and they are now doing that care as we speak. >> okay, great. >> we want medicaid plans. >> great, questions. >> mary grant, policy director of the coalition to transform the dead scare.

these models are great. hopefully they will continue to be successful. how will we coordinate models into the future? if you are a frail elder who needs a hip replacement, are you in aco but also part of the independence at home and then it's the bundled payment. i know that the demos are projects which they need to be from his standpoint, but how is it going to come together? >> from the underground, the patient population has to drive the financial models and not vice versa. you have a lot of silos of different financial models, but we take care of the patient until the last day of life and all of the care for now is independence at home. we right now are not in aco because right now they are

mutually exclusive and we don't participate in bundles either because that would interfere with the shared savings model. right now i.e. h. is a standalone although a fully coordinated program. that's the way i think for now it needs to work. >> other examples like that payment entity plus in aco and mechanisms on the backend if you will to ensure we are not double pain but also align in centers and weill continue to work on those issues. >> what we are going to find as these things fall out, we find financial mechanisms that are working. they will become the standard for how they're paid for and organize. we have to work through those issues. we worked this is 20, 30 years ago. that is the medicare did that in the rest of the industry solid line peer will find that as well as these models.

>> i think we are going to need some help for consumers for a long time and the whole idea of almost the ombudsman is really important. there's an area where you have to worry about the relationship between medicare and long-term care -- long-term supports and services. one of the things good for medicare to be able to do over time is to provide not only does ombudsman kind of services, but potentially even a structure to help people manage long-term services. that might be an add-on program that people would enroll in an pay a modest income related payment and which they could get help in managing the system. to think of managing it yourself is pretty scary coming even when

it's a help of a family member. that is an area we really need to think about. maybe even a model unto itself in terms of innovation. >> i think we are wrapping up because while we do have more questions i don't agree can get to her questions. i want to thank for the discussion and panelist. i want to give a plug for our primer, which at least two other panelists were gone. if you haven't learned everything you needed to know about payment delivery system under medicare, heuser cici right now. i want to thank you and think maryland. >> those within the remit of your packet. though some of them you can see a website debbie debbie w..all-stars.org. thank you to our panelists for an exciting conversation. one more plug.

the shirt and streamlined valuations. thank you very much. [inaudible conversations] .. [inaudible conversations]

let's move to the microphone.