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free mobile video app or live on c-span.org. ♪♪ >> thank you very much, ladies and gentlemen for coming. our topic today is medicare. the largest healthcare player in the american system. a huge and growing federal entitlement. a little more than 10 years, medicare will increase in enrollment from 65 million to nearly 80 million enrollees. total program spending will double. today roughly it is $1 trillion and within 10 years it will be nearly $2 trillion. at the same time, medicare is rapidly changing. today, roughly half of all senior citizens are enrolled in medicare advantage. a system of private coverage

which is the leading alternative to traditional medicare, -- what that means is that government makes a contribution on behalf of a beneficiary to the beneficiaries chosen plan. given current trends, medicare advantage will soon be the dominant form of medicare coverage. the question before the house and before the nation is a very, very big one. how do we provide high quality medical care to a huge and rapidly growing older population at a cost that is affordable, not only to seniors, but also to america's taxpayers. in our new book modernizing unmedicare, from johns hopkins university press, one dozen of our colleagues in the health policy community have provided very specific answers to that question. three of them are care with us

today. brian miller is a practicing physician and assistant professor of medicine at johns hopkins university and a fellow at the american enterprise institute. john goodman is president of the goodman institute. doctor goodman is a prominent healthcares economist and he i widely known throughout the united states as the father of health savings accounts. doug is president of the american action forum and a former director of the congressional budget office. now with a debt limit facing the country, you can expect to see them on your national television shows dealing with the debt limit and all of the other problems that are connected with it. with that, ladies and gentlemen, i would like our guest to come up and join us.

we will have a discussion about medicare. >> brian, i will start us off with a question for you. right now, as you know, millions of senior citizens are voting with their feet. and enrolling in private medicare advantage fans which is a defined benefit program. as opposed to traditional medicare which is a defined benefit program. you deal with this in chapter six of the book that is been published by hopkins university press. what are the inherent trade-offs facing seniors when they have to make a decision about whether to enroll in traditional medicare medicare advantage? >> first of all, thank you for having this event in the

conversation about the medicare program. two different programs. traditional medicare medicare advantage. when youal are in the employer-sponsored market and you pick your health benefit, you are signing up for a health plan. you are purchasing a plan product. when you end up in the medicare marketplace, things are a little different. you turn 65. you sign up for traditional medicare. a+ b benefits. hospital benefits and also physician benefits. then you also have to pick a prescription drug plan. no catastrophic out-of-pocket limits. eryou then pick supplemental coverage. the alternative, of course, is picking medicare advantage where you have one choice. traditional coverage, supplemental coverage, 90% of

plans include a prescription drug plan and then you also get supplemental benefits frequently two thirds have dental vision and hearing. if you are 65 years old and turning to medicare and you have three-five conditions, on a ssfixed income, a limited number of assets, you cannot spend all that you want to. making one choice in getting an integrated health benefits package is something, for the average consumer, it is actually much easier to make that choice. it gives them financial protections. they don't have to make as many choices. and then the trade-off, of course. the cost for the beneficiary is they accept a network. they can see the doctors in the health plan network. you were working for 30 years,

yet healthcare insurance for your employer. you had a network. you could not see every single doctor. that trade-off for today's retirees is not so scary. there is usually some review and some controls. the beneficiaries i will get more benefits, i will get more financial protections. some limitations on how i use that. >> more convenient. >> richer benefits, more convenience and frankly, easier to choose. making one choice instead of three choices. >> the other evidences, with so many plans it is basically more affordable. >> it is more affordable to the beneficiary. if you are to purchase traditional and pay premiums, you havee to pay prescription drug plan premiums and then you have to pay other premiums and

good luck being 70, 80 years old and trying to get vision dental or caring coverage in the private market. you get it through your medicare advantage plan. >> john, in 2003, republicans in congress enacted the medicare modernization act which created the medicare advantage program. the alternative to traditional medicare. a few years later congress, with the supportrt of president obama enacted the affordable care act called obamacare and that created a system of private plan competition and state faith health insurance exchanges. on paper, they look very similar they seem very similar. you make the argument that they are quite different in medicare advantage works better. would you explain why that is

true. >> yes, they are very similar on paper and very different in practice. that is why 50% of the seniors are in the medicare advantage plan. over in the obamacare exchanges, the non-subsidize part of that, it was going away because no one was buying until congress came along and added on subsidies even for people making half a million dollars a year. medicare advantage is the only place in our healthcare system where if a doctor discovers a patient has a change in medical information they can forward that and get a higher premium. that is why you have special needs plans that specialize in diabetes and heart care and other illnesses. wanting to attract people with these problems. the only place in the healthcare system wherela this happens. there is no employer plan in

this country with an employee with high healthcare costs. there is nobody in the obamacare market. they are all trying to attract the healthy and run away from the sick. in regular traditional medicare, 10,000 things that medicare pays doctors to deal. not one of those tasks has objectives or states that your job is to make the patient healthier or to cure disease. over in the medicare advantage plans by contrast, people lose money if they don't cure diseases and make people healthier. this is georgia alverson. former chairman ceo of kaiser who says in the medicare plan, 20% of patients get -- 20% of those turn into amputations. this country spending $8 billion

a year on amputations. over the medicare advantage plan , even in the moderately successful ones, they have had this many and one third as many amputations. >> they do things that are probably not on the list. one ofat the ways you prevent amputations and ulcers you make sure your patient has dry feet and dry socks. i don't think dry feet dry socks are on the list of things traditional medicare pays for. blindness is another problem with older diabetics. a much higher rate than theor medicare advantage plans. $100,000 a year, 20-30,000 dollars a year for blindness, congestive heart failure we have a significant difference in outcomes in medicare advantage and traditional medicare.

so, these plans are differently than regular medicare. their financial incentives are different. halverson says the death rate is 40% higher than it is in medicare advantage plans. i will say that one thing, if you readd what george halverson as to say in the kind of articles that have. , you would think we are describing two different worlds. my only problem with halverson as he calls it fee-for-service and he calls medicare service capitated. some of the best plans pay fee-for-service. the distinction is not how the doctors pay. over here we have integrated coordinated care with the objective of keeping people healthy. ooover here it is not integrate, it is not coordinated. people actually make more money when the patients get sicker.

>> thank you very much, john. in chapter 12 of your contribution to the book, you do cost estimates that show that a comprehensive defined contribution often referred to as premium support system driven by consumer choice and a rather robust competition would result in major savings for both medicare patients and also taxpayers. your focus, your chapter focus is primarily on taxpayer and beneficiary savings. i think the question, though, for a lot of americans would be, is the need or the desire to move into a premium support system a comprehensive defined contribution system. it is a desire to reduce healthcare spending the only

reason for d moving in that direction or creating a premium support system in medicare? >> absolutely not. i focused on the budget costs in the beneficiary -- [inaudible] [laughter] >> very good. [laughter] >> the more important is telling the cbo what to do. >> i want to try it more often. >> take some lessons that we have learned in other settings, medicare advantage being one of them. the power of having competing plans. what benefits, what things in addition to the care allowing them to stay in better health, improve their outcomes. look at the medicare program where we harnessed private negotiation between manufacturers of pharmaceuticals

and the planned sponsors to deliver robust competition. let individuals pick among those plans to get the formularies that match their needs the best and the outcomes that they ceprefer. in that process, we get a high beneficiary satisfaction. eighty-90% are extremely happy with where they are. it is way cheaper for them and the taxpayer then i anticipated back in 2003. we have learned that we can infuse into the healthcare programs, respect for individual value, they get to decide what they think is important and the robust competition of t the private sector in order to serve both the taxpayer and the industry, respecting the values and enhancing the competition

are important in themselves. i would just stipulate, we need to, fun fact that you should not use that polite cocktail parties because you are around friends, the medicare program by itself is responsible for one third period. >> are program bleeds red every year. we want to get that under control on behalf of the president of future generations. we want to serve beneficiaries better and this is a way to do that. >> that is an important point. aside from the fact is spending so much money, contributing to the national debt. medicare is covered by a very powerful medicare regime. the medicare bureaucracy referred to as the center for medicare and medicaid services. cms.

for years, of course, this bureaucracyy sets prices as john points out, prices for 10,000 medical procedures and over 3000 counties throughout the united states. anapparently, does not do a real good job at that. medicare advantage basically introduces a new dynamic into the system. that hasas an effect on the medicare bureaucracy. i was going to ask you, brian, as a medical professional dealing with senior citizens and so on, how does medicare advantage as a system, this competitive system of private plans, change the role of cms in the lives of your patients of senior citizens? >> i want to respond to something doug said about beneficiaries and choice. i have this patient that at six a bunch of meds.

pretty smart old lady. helped her get modifications to her bathroom so she could get in and out of the bathtub. a chairlift to go up and down the stairs. on a fixed income. she was on a decent plan. medicare, medicaid dual eligible i remember talking with her and she did not have good teeth she was going to get her teeth pulled and get dentures and go to the dentist. she said i picked one plan that would let w me do that. i said, okay, but what about all your doctors? >> she said i picked a new cardiologist for this year and next year after i get my teeth fixed, open enrollment again i will switch back to my other plan that s has my old cardiologist in it after she got her teeth fixed.

beneficiaries can be pretty crafty, pretty smart in a good way. she beats a multibillion dollar company. sort of fun for me to cs or physician. to think about that, if we improve theth plan finder and ge beneficiaries better choices, show them how they can shop for their package, we can empower consumers to make those choices and drive beneficiary satisfaction. cms rightht now is very much focused on payment levels. the annual cycles, all of these happen. 1500 patients recently. that favors people inside. sitting there and reading this role inri analyzing it for the appropriate stakeholder. then you have the usual cycle of

medical specialty societies that show upp around the time of course that the levels are set in their are a stream of people going into the various buildings in the capital. focusing on paymenter levels. all of these bureaucrats focused on payment levels. transitioning from volume to value. because it is an integrated comprehensive benefit package that allows the potential for cms to stop focusing on writing 1500 page level roles and instead focus on these rates. focus on plant regulation and start to set population health goals. something that both parties actually want for the program. >> benefiting seniors. very good. can i express a concern? >> i do not think that cms understands there is a fundamentally different delivery platform than the fee for

service. if you've got in and ma plan with the quality of standard, you are providing the divine contribution. a?why do they need to know what happened in the counter data? >> trying to micromanage the plan in a way that people are sitting here trying to accomplish. deregulate the delivery system. i worry about the future much less getting to a more robust form. >> all right. good point. john goodman. in the private sector there, you are largely responsible for this in many ways as a result of your work in congress many years ago promoting relentlessly the idea of a health savings account so people could make money,

tax-free contributions, to build up an account where they can use that moneyn for routine medical services and protect themselves against unforeseen health consequences. we have millions of americans today who have health savings accounts, but we do not have it for senior citizens. why cannot? >> okay. here is something a lot of people do not understand. the health savings account for non-seniors is a best savings account that there is. better than an ira, better than a 401(k). the reason it is better is because during your working years you can save and at the time you reach 65, you can use your health savings account deposits to pay your part b and d premiums.

even if you are healthy for all your working years, you will probably exhaust your account paying those premiums during your senior years. you will never pay taxes on that money at all. when congress created this account, they realized if we allow seniors to get a tax deduction for deposits to the health savings account and they turn around and pay their premium with it that is equivalent to allowing them to deduct the premiums. we are already giving so much to premiums they were not in the mood to give another tax deduction to this group of people. there is a solution and i call it the law health savings account. you do not get a tax deduction for making a deposit. you put tax dollars in the avaccount, but in this way we he

an account that is not very expensive from a budgeting point of view. it would allow the third-party payer to put money in this account for the chronically ill. you may say to a diabetic we will put money in an account for you. if you are compliant with your drugs and you stay away from the emergency room, that money is for you. if you are not compliant and you go to the emergency room, you will pay the costs. you get the benefits of your good decisions and pay the cost of your bad ones. seniors need an account, it just needs to be a roth account not a traditional savings account. >> the components of this concept of defined contribution, as a way to finance medicare, referred to often as premium support have often demonized this as voucher rising medicare.

>> we will break away from our book tv programming for 40 plus year commitment to covering congress. the u.s. senate is now coming in for what we think will be a brief session. no votes will take place. lawmakers are in a month-long recess for their state work. now live to the senate floor care on c-span2. the presiding officer: the senate will come to order. the clerk will read a communication to the senate. the clerk: washington d.c., august 25, 2023. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable

brian schatz, a senator from the state of hawaii, to perform the duties of the chair. signed: patty murray, president pro tempore. the presiding officer: under the previous order, the senate stands adjourned until 11:45 gor citizens.journed until 11:45 gor a certify a voucher where they would have to go out and negotiate with private health insurance company and was the source of the demagoguery mean it was the idea that, you know, and i've always i, i remember i got into a rather spirited debate somebody in the media and i asked them i said, well, let me ask you this. does the federal employees get a

voucher? and of course, the answer no. and you know, this has been going on for a long time. i think the point of it was psychological. it's really scare senior citizens that they would be left alone somehow. but basically the yeah i mean, this was the oldest thing in politics. get there first try to characterize your ideas as their ideas is bad and there's the war over getting their initial characterization an attempt to to damage that brand deliberately. people still the terms trickle down economics remember, i have no idea what they're talking about at this point. it's just the words they've they've chosen to signify. they're just they're just like the thing. so the most important part of that story that gets lost is the one that john pointed out at the beginning if you're sick or you get more if you need more care to get outcomes, the system provides with more resources, and that's that's far from a voucher it and making it just a certificate everyone gets that's tailoring it to needs of the beneficiary which is what we ought to be doing right and if i

you know, it's interesting also that the private medicare marketplaces that competition produces health benefits, innovation, which is not an oxymoron. right. you know, not something that you see on a slate tv commercial or in the movie office. health benefits, innovation is a real thing. if you go back to the 1980s and you look at private medicare plans, medicare fee for service didn't have a prescription drug benefit. something like 4/5 of private medicare plans in the eighties. right, when we had the brick cell phones. so fast forward 2003 passed the ama, get that prescription drug benefit, which is an option for fee service beneficiaries subsidized by the government delivered by the private marketplace through private competition. that's 17 year delay. and if you remember the recent debate we had over adding, you know, progressive wanted to add dental vision and hearing to traditional medicare. well, where did that come from? that came private market competition, a marketplace where

those are already available. so i think that one of the things that this shows is that for the future of medicare for beneficial is actually private market competition, something that will benefit them. right. let me ask you this. what do you think is the source of this intense opposition to, this movement mean? i'd like to ask all three of you this the idea of transforming medicare into competitive market. what what what is the real guts what is the real guts of this position? >> it comes from the idea that self-interest is a bad thing in healthcare. and have you ever heard bernie sanders say there should be no profit motive anywhere in healthcare he really believes it. and he's not the only one. i think that's the biggest problem. they don't like markets every

healthcare stakeholder i've talked to is for innovation and change it's not disruptive and doesn't pamess with the payment style. >> i would say it's something different. you know when that's gonna come out it's comments, the payments pages of comments with financial stake in that. done the final it's a centralized authority that can go argue with. if we take that away or create one of many options then they lose the power the loss of

control basically what you're talking about is a radical reduction. >> my generation will finally be able to afford a house. as millennial's. epic comes troll in the hands of the beneficiary. the medicare program if we start to work on these changes slowly over time. >> our colleague at isa meyer

all the activity in the house and the senate is ultimately trying to figure out how to do the formulas to get the right formula. we are looking at what seems like crazy spending within the congressional ãthe idea of annual trillion dollar deficits

we are looking at a situation we are accumulating a very large and dangerous debts. your friends at the cbo talk about physical crisis. americans don't understand the gravity of this i don't know how far we are from it but in the case of medicare advantage brian kind of following up but how do you see this contributing to the promotion of long-term fiscal ãyes it

would be a nice change. at something we don't get very often. we need benchmark report. if the basis upon which the federal government makes a contribution to the different type of plants. >> right. so that is something that needs to be addressed and i think policies to eventually address but medicare advantage it's like putting your house on a budget. we have the mortgage we pay the grocery bellow, medicare advantage structure the same way its risk-adjusted capitation so it's risk-adjusted for health, per member per somonth or per beneficiary per month. that's a good framework for budgeting. we can debate about what the appropriate capitation rates are we can say with the

appropriate risk adjustment methodology and we should have those debates everyone is having those debates right now and medicare advantage it can be quite exhausting. article after article about medicare advantage risk adjustment. general principles of having a population-based budget for the medicare program is something that could allow us to potentially budget for medicare for maybe the first time in ever. >> do you have observations on that? >> i think that's the single most important thing you can do for medicare from a fiscal perspective is to have it on the budget at the moment everyone has an open-ended draw of the treasury and behave accordingly. if the providers the device manufactures the pharmaceutical amanufactures the beneficiarie all realize there was an amount of money available to do the things they would behave

differently. there's a lot of agreement across the aisle on the left if you want to talk about how we have to create in the medicare program bundles would have a hip bundle and set of services there is a bundle quality.com. that is putting that set of services on a budget and asking for quality outcome on the right you have medicare advantage it's one big bundle it's got this capitated contribution that's it. there's an agreement about how to do this step this is more comprehensive neither is perfect. there's a great deal of improvement i think would come from better quality metrics is the consumer willing to buy your service. that's the advantage. there's not much disagreement just a scale. >> if the scale. okay that's pretty remarkable.

do you think there is actually bipartisan. >> i didn't say that. >> at the level of policy design there's an agreement about the incentives. that's what you see going on. selling reforms and getting legislation in congress. the medicare advantage market is increased by one absolute percentage point every year for the past decade. recently surpassed 50%. >> because the family foundation came out with a report it's 50% now which is quite remarkable. what's even more remarkable is that our friends who write the medicare trustees report every year have always underestimated the growth of medicare

advantage which i thought was interesting. i want to ask you about your provocative proposals in the. most people think when you sign up for insurance you should sign up once a year and that's it. we want some stability in the market and we have a season people make their decisions they enroll they get their coverage and that's it until the next season. we been doing that in private health insurance forever we do it in the huge federal health program and medicare advantage. you, however john, want to change that. you want to have a situation where people can make a decision to enroll in different

plants. when they think they should enroll in different plants. why do you think there ought to be a continuous open enrollment. the insurance company on the other hand is not start.after you made your choice and open

enrollment period ends they can change your network and this has happened. there are some tragic consequences of this happening. where people have been denied access to cancer specialist if they thought they were to have access to it. you are right the insurance industry says we had continuous open enrollment that would be destructive although i will point out we used to have in the individual market continuous open enrollment. what i propose is that you be stuck with the plan you choose unless your health condition changes you have a new health condition you should be able to go immediately to the special-needs heartland. change in health conditions, change in the network that you have access especially if there

was a doctor treating you and the doctor is no longer in the network. that ought to be a condition for switching plants. let's call it partial continuous healthcare enrollment. >> how do you respond to folks in the insurance industry and elsewhere who might say john that sounds great but you are promoting adverse selection of the system we will have more instability in the market as a result and that will jeopardize the viability of a lot of plans if we actually had that kind of assistance, how would you respond to that? >> the asymmetry is fair. the insurance company can change network at the drop of a hat. the patient can't make switches. i think ããannounced his staff from the several medicare advantage plans for several of

them the networks or ghost networks the doctors claimed the network wasn't really there. to me that would be grounds for allowing we need to make it possible for people to switch plans especially when their health is at stake. not because they just happen to change their minds but for some serious healthcare reason they ought to be a way to do this. remember, the whole idea behind medicare advantage you have risk-adjusted premiums and your health condition changes you your plan is entitled to different probably higher premiums and and that's the way works orks that's why it so well that's why we have special needs plan. >> let me follow up on this a little bit. >> there is a special enrollment period. >> you have medicare advantage

you nthave six week period and then you have a few more months when you can make a change. beyond that you can't change plans until the next open enrollment period. >> it sounds like what you're proposing is really just for exogenous things that happened to you. have special enrollment periods much more generously to allow people to switch. >> yes but it needs to be and needs to be close to continuous open enrollment. >> you have an event to get four weeks to go health condition change provider network change.

>> remember, we are talking about somebody who used to sell congress what to do. cracks in the exchanges here an example in virginia a couple had a daughter a rare cancer and this is the only clinic in northern virginia that dealt with this cancer and they chose the plan after the open enrollment closed the plan kicked in and by the way, in the amount of exchanges if you go out of network it's nothing. almost everywhere. this family was really mistreated. i think that's wrong. >> we are talking about continuous enrollment and it

brings up another question, this is the way in which we have a risk adjustment corporation. some of the arguments especially by some friends in elevators is that the risk adjustment is so flawed it such a fundamental flaw. it basically it's an argument against the system. risk adjustment as a carpeted area but if an important area with regard to medicare advantage and medicare advantage going forward. do you have thoughts about how we can improve the risk adjustment system? >> the most important thing would be tto stop developing t risk measures on the fee-for-service population that

applies to the medicare advantage. you got to do the risk adjustment on the ma population. risk adjustment is different than forecasting the particular procedures the patient is going to get. people start going down that road and in a fee-for-service mindset. stop tinkering with all the stuff in between. and over tinkering.

>> what's happening in the health affairs articles is comparing the medicare advantage plan to traditional medicare the problem with those kinds of comparisons is not medicare advantage doctors know or they should know as over traditional medicare there is no extra payment for doctor being careful to get everything down on paper about the patient's. the recent article in the new york times made a big deal about the fact that among the medicare advantage plan some find more heart disease than others the implication was that these are finding a lot of problems and making it up.

i think the plans are finding a lot of problems. is in the financial interest i don't think they are making up those numbers. the prediabetic is prediabetic these are not all equally good. if i have one overall improvement that need to be made in medicare advantage it needs to be more competitive. the plans that ought to lose it they ought to go out of business. the best plans in houston you have diabetes that make insulin free they make that's free. it's free because it pays. to keep the patient out of the hospital and you make money. the more competitive we make i

the better quality of care. i agree with you john, and traditional medicare you don't have an incentive to code all the diagnoses. my iphone in my pocket there's an app that tells me if i diagnosis coding in the hospital i get an alert doctors ignore the mentor ship reminding or oversight fee-for-service is probably under coded. coding is fine. coding for something that's not usually there.

adding clinical specificity. adding clinical specificity is good for clinical communication. if the plans are finding more diseases or coding more diseases is more accurate i'm not really angry at health plans necessarily finding the diagnoses or more specificity they say they're finding more ã we should give them an incentive to use that information to help beneficiary. the ather than eliminate incentive to code appropriately. >> we have a lot of work to do.

this will be some serious heavy lifting. is that right? >> let me ask you this do you think there is a bipartisan that there be a bipartisan interest in reforming medicare advantage? >> that's an interesting question. you have to understand the democratic onmind. they don't like medicare advantage because those are for profit. they like medicaid i'm not sure they realize it most medicaid patients are being taken care of by for-profit managed care companies. if they could get over that,

yes of course the two parties come together a lot of this is just common sense.

what is wrong with thinking about how we can be more physically responsible for medicare and creating better platforms that future generations are my generation. i would like for you to expand on this a little bit. the whole point of moving to a comprehensive defined contribution system premium support. to basically make the choices best for them. cannot drive efficiencies in the healthcare system but here's the issue, and you hear it over and over again. population that's older 65 3,580 and so on.

is it really a sensible strategy to make these choices effectively. the complexity of healthcare ordinary people cannot actually make the decisions and experts only could make these decisions. you talked about this tell us when you think about that problem? >> we are not asking for someone to sit on a desert island and iron it out. somehow in healthcare alone

make these were the company decisions is just red herring it's not the reality. we make complicated decisions a lot. how does it work? >> you have advisor networks. we do it in the product markets. we do this everywhere in the economy. i'm still not sure why s but ¦ there participating in other places. getting the help they need to make them. everyone said they will never be able to do this.

>> are the most natural person about healthcare plan. the physician could not tell the patient if the patient was an accountable care organization which had some of the same financial incentives as american advantage plan. even under trump their simulation. a doctor cannot encourage his o patient to have a medicare advantage plan that he's part

of. in order to look for a house your booking.com first looking airfare hotels in the amount of time he makes complex decisions on time. we can and should do that for medicare. bring them on equal playing field. why we think about how we apply risk adjustment to all market disciplines including traditional medicare. why don't we apply star ratings traditional medicare. none of it should be a handout or subsidy to private plan. we need to treat the market purchase is a viable iopublic option and perceptive future.

we all are participating in many complex sectors of the economy for example like financial planning and so on. many of us limited the expertise in these areas. we rely upon families and friends and so on. in order to make the decisions and i'm told by the economist of course of course that's you guys that they're all market leaders in many cases. maybe you get 10 or 12% of the entire demand side of the equation. it seems like in this case medicare advantage seems to be going pretty well. >> ladies and gentlemen i think we are coming to the end of our program. over the next 10 years we will

spend a lot more medicare than we do today. and with rapid medical technology the cost of delivering medical care on capital basis is going to increase the issue is really not so much how much we spend but the ultimate issue is are we getting rethe best value for our medical dollars. our colleagues who have contributed to this wonderful effort that made the choice and competition in fact ork.