the addressing of the risk factors. i'm glad everyone's looking at obesity and mary ellen knows that i've worked on obesity when i was in practice in arkansas. it gets to be quite hard. we were fuelly ll actually on commission that set up bmi on kids in school. imagine when you -- how do it, no one else knew the bmi at home, but we had 33% obesity in school-aged kids and doing measurements, taking vending machines out of school, et cetera we levelled that. now we didn't impact the 48% smoking prevalence or tobacco use, i guess it was dipping as it was smoking. the other thing is, when you do action on data and one program i'll mention is the door to balloon, which means from when a patient with acute m.i. hits the e.r., the door to the e.r. until they're blowing up the balloon in the artery to open up the

vessel, we know that if you do that under 90 minutes you save heart muscle and as a result you don't have as much congestive heart failure, so you reduce the morbidity. now we went from about a 50%, 60% in the e.r. to 90% of all e.r.s hitting that and hospitals hitting that number, and that probab probably saves two to three days of hospitalization and also puts the patient back to work after three to five days as opposed to what we mentioned when eisenhower had his heart attack and admitted to fitzsimmons army hospital he sat in the hospital with little heparin and prayer. they have a little room for where he was at the hospital there now. but where do the savings go? the cardiologists didn't get

paid anymore. here's program that actually had savings and we still haven't figured out whether they were -- the hospital got them through drg or the insurer got them. whatever we do with the models we have to look at what joe said, there has to be some incentives built in so that if you are doing this extra stuff or paying for this data, and finally the other thing we have the registries that we can actually track outcomes. maybe when the electronic health record gets to where it should be, we can do it that way. but data, disease specific, procedure specific outcomes over longitudinal time and that really tells us, someone mentioned in the trials, they tend to be like most of us up here, middle aged, bald, white males. not all of us. but we are the -- obviously the trial, the people in the trial.

and we don't reflect the makeup of society but with a registry you see actually what we're doing and how we're treating. data, data-specific, give gate da data to physician so physician can act on it and greater physician and patient interaction and shared decision making. thank you. >> great. thank you, jim. diane rowland, in our capacity, both at kaiser family foundation and mack pack, you've been thinking about high-cost patients and challenges to delivering coordinated care, improving health outcomes and lowering the costs. so tell us about that thinking. >> thank you, susan. i think i can just do it with this. this arrow? >> well, i always come to these forums and we talk a lot about the medicare program and sometimes we talk about private insurance and we don't always when we talk about health care costs bring the medicaid program

into perspective. i just wanted to remind us about why medicaid takes care of lot of people with chronic illness and why it spends a lot of its resources on that population. and of course, this is our most classic slide, showing that one in four beneficiaries on the medicaid program are disabled and elderly but account for two-thirds of the spending. and a large reason for that, of course, is that there is a lot of long-term care expenditure on behalf of the populations. but let's focus for just one minute on that under 65 disabilty population for medicaid and we like to talk these days a lot as melanie mentioned about the duel eligible population. there are 9 million people with disabilities on medicaid not elderly and mote of those people are actually not dual eligibles, only 2 million of them are dual

eligibles. one of the challenges in the program, and ken alluded to it to get better coordinated care, better services to the disability population for which m medicaid has whole responseabilty and where it has a range of services, care coordination, case management or part of the medicaid benefit package, and could be much more effectively used on the pop population with disabilitiedisa. this is a slide,er we're used to seeing in every part of our health care system. there's only a few people who account for the majority of any spending. and in medicaid the top 5% really account for a substantial share of that spending and the few people there that are children and adults are relatively small but high cost. really there is largely driven by the disability population. when we think about the disabled on medicaid we have to remember

they include substantial share of the population with severe mental illness and it's often when you look at who is a high cost beneficiary, it's the combination of one or another of the disabling conditions combined with mental illness. and so a diabetic, i think ken looked at this, someone with diabetes is being treated with a mental illness is at a higher cost and less likely to follow treatment protocols than someone who is just a diabetic. so that is a real challenge and especially as ken even alluded to, much of the medicaid care coordination through managed care carves out mental health and manages it totally separately, and now much of the drug costs is also carved out in many places, so that you don't have the integration for that disability population that could help. but we are focused increasingly -- i have to make

sure i get the right arrow -- increasingly today on the share of medicaid spending that goes for the dual eligible population. and as you see from this slide, there are about 15% of total medicaid enrollment are people who have both medicaid and medicare coverage, but the -- and they account for 38% of overall spending. and a huge part of that is long-term care services. but i'd like to point out really if you're trying to manage that low income, disabled population there's another 10% of the medicaid population that are disabled and a few nonmedicare eligible aged that account for another 28% spending. so i would say within the medicaid program we really need to look at how to really better manage and actually there's a -- an ability in medicaid to do more on the preventive side, more on preventive services,

more sending people to treatment programs like the diabetes management program there's. so the opportunity within medicaid is broader. and finally, though, if we look at the people who are dual eligibles, they really have a substantial share of chronic illnesses, 55% of three or more. i also think that a lot of medicare beneficiaries have very similar levels of functional impairment. i mean, it's different but it's not so substantially different on chronic illness. it really involves really thinking about how you manage the cognitively or mentally impaired pause that's where the biggest difference between the dual eligible population and other medicare beneficiaries occurs. so in conclusion, we're really now looking at -- and melanie's alluded to being able to put together medicare and medicaid spending. in this analysis with the urban

institute, within the dual eligible population are there some higher spenders and some who are lower. and we found if you look at top 10% of medicare spenders and 10% of medicaid spender there's are somewhat different people though both dual eligibles and only 100,000 people fall into the category of being a high spender in both medicare and medicaid. and that's largely because, as we need to look forward at different ways to look at these populations, the subgroup analysis which melanie alluded to is so critical. you see that the top spenders in medicare are really top spenders because of their acute care utilization and those are services that medicare can and should be able to better control whereas the top spenders that end up on medicaid are often in nursing facilities and are also people who are using long-term care services in the community.

and they actually spent a little less on acute care because their big spending is on long-term care. in conclusion, i think as we look at and try to figure out how to better manage both technology, where there's not a lot of it unfortunately on the long-term care side, so most of the technology care would come in looking at acute care services we need to also think about how to manage different types of chronically ill patients and how the two programs can either work together better or work better within each program for the chronically ill. and i think that's where we will see better outcomes and lower costs if we can really zoom in on the disability populations and the differences by subgroup. thanks. >> thanks so much, diane. well, bruce chernof of s.c.a.n. foundation, wuf been thinking a lot about the same group that we've been discuss, those with rising preference of chronic

disease and the age. what else do we need to know about this population? >> thank you, susan. i want to pick up on where diane left off. i think the last couple of slides are incredibly important in our thinking here. and as we wait for the slides to come up, we're almost there, folks, that looks good. terrific. so as i zbbegin my presentation wanted to start in a similar place, which is that you have to really look at the folks who are getting care and what their needs are, and that really helps us think about targeting and building better programs. and i think building off this notion that the medicare and medicaid high spenders are different is a critically important thing for everybody to take away today. and my first slide sort of picks up on that point which is, those

with chronic conditions, that's only hal of the battle. those with chronic conditions and functional limitations together drive a lot more of the high cost medicare spending, and will it come to why that is in a second. we spent a lot of time talking about people and their diseases, being defined by your disease. well the reality is that, function is an incredibly important piece of this, your ability not only to care for yourself in a medical context but care for yourself in a personal context. and when you start to factor in this notion of function, function in the way you live your life, not the way you live your medical life, i want to pick up on something joe said at the very beginning and turn it on its head. consumers aren't patients in waiting. patients are people in waiting. trying to get back to the place where most people, even those ce chronically ill, those who have cognitive impairments or serious

mental illness, they're people most of the time they spend their time out and about in the world and that world is not confined by hospital beds or doctors offices or triage centers. thinking of the role that function plays in disease and the way that function plays a role in people's lives is incredibly important if we're going to look how we build effective programs and target appropriately. and this chart simply goes on to say that when you add in functional impairments, regardless of the number of chronic conditions, functional impairments is a really important cost driver in the lives of with chronic illnesses regardless of the chronic conditions that they have. again, echoing off of diane's point which is how do medicare and medicaid hold hands? i know why you're here, it's this slide, who are the duals who are the preduals and what this slide start to raise is

this issue of preduals what is a good dual program look like? when you look at individual whose have chronic illnesses and substantial functional limitations, half of them are duals but roughly half of them are not. these are folks who run the risk of spending down, because their medical problems get them by the tale and becoming duals. in an environment as we watch boomers start their retirement, we see folks with fewer financial resources and they might have had earlier on, this becomes a critical problem sway cost driver over the next 10 or 15 years for us. so when we in the s.c.a.n. foundation talk with folks about what they really want we decided that we would do almost 20 focus groups across the country last year and a series of polls, and what we did was to choose to talk with individuals who are 45 to 65 and really in a care

giving role and throws 65 plus who are either care giving or care receiving. and this represents a word cloud that sort of looks at the most important language that folks used. and i think it's really important that we look at this because these are all individuals who could exquisitely describe either the care giving or the care receiving processes. and you know i'm a general internist by training, i love the medical system as much as the next guy but i offer there's little medical stuff on this slide. with all due respect to a lot of the great programs we've built, you don't see this riddled with disease management, pal laive care, hospice, it kind of go backs to my earlier point which is function is incredibly important and individuals define themselves by the function they retain. if you look at the words that are up there, like community and independent, i mean that's how people think of themselves and so as we start to think about

the kinds of solutions that we want, where does technology fit, why is this a technology talk, i want -- i want to leave you with a few points. i think the points really are that you have to ask, what's the problem that we're trying to solve here? so there's very little evidence de -- picking up on a point -- surgical robots add much value. the reality that is surgical robots, at least at this point in the time for the data available serve a marketing problem for hospitals. it's good to say your a robot and surgeons love them. it actually is kind of keeping your medical staff intact. that's a different problem. solving a marketing problem is way different than solving a clinical care or care coordination problem. when we start to look at population that has substantial medical problems but substantial functional limitations, thinking carefully then about the problem

you're trying to solve is key and it really may be that it's more of a low tech solver. so what's the role of the telephone and the pieces of technology that do work where there is evidence? remote patient monitoring, places where a little bit of technology, a small investment can go a long way. if we're going to introduce ex-technology, what is the problem we're trying to solve with it? the second thing about technology in this environment, in the environment that diane described and i'm trying to build on, technology is not an end-to-end solution. technology rarely solves any problems in the seriously chronically ill functionally limited person's life. it is a tactic, not a strategy. so at the end of the day, to just introduce a piece of technology is going to get you nothing but costs, and actually may be more risks than benefits. most older individuals when they get sent home from a complicated hospital stay get technology,

the dme comes out and drops something off. if there isn't a substantial and robust plan, that piece of technology may bring more risk than benefit. and so i -- it kind of gets to the point that technology without a good care coordination plan is of questionable value. i think that as we build systems, and really melanie, as we think about the work that you're doing in the care coordination office, it's not just about the medicare model of care in that sort of nice model of care way we like to think about it. it is the model of care coordination and person centered care coordination that is going to be at issue here. as you look at the states who are proposing, you know we would encourage you to look hard at not just is there a plan for the pills and the this is and that that thes and ins and out of the nursing homes but what is the land that supports people's goal of retaining the function that

they even if they have serious illness or functional loss. my last point, picking up on one of the comments in the aud yent is this issue of targeting. targeting is really, really, really important. and you're not going to solve again, i think diane's slides hint at this, for the high spending medicare population, you know, medically oriented solves are going to take you a long way. and so the nice article published in health affairs that cover the data make the observation that's a place where a medical home may make a lot of sense. you folks with lots of doctors and nurses and pharmacists and others and coordinating the medical cats is half the battle. that's a good place to start but for the medicaid population where the needs may be more functional and community based, the model of care may look very different and the medical home may not be the solution because the problem with the medical home is, you know, we're glad to talk to you in a medical context or come right in, we have the

same-day appointment but for somebody's needs socially related being drawn into the mee solution. so we really encourage that technology to be used in a targeted fashion. and that, you know, what is the problem you're trying to solve, are we really looking to solve a medical problem or a functional problem? thanks. >> thanks very much, bruce. and now to susan reinhart, now that susan that we know who the chronically ill are, that their needs are not all the same, and we talked about consumer engagement or patient engagement or person engagement, and shared decision making, how do we bring all of those things together? >> thanks, susan. i figured you left the best for last because you wanted the patient perspective, which i'm happy to try to bring to this discussion. can you hear? is this on? okay. so what i wanted to talk about is this idea that i know ken

does such a great job in all of this work, talking about the need for better patient and family self-management, and the need for tools for that. so as we talk about who are the chronically ill, how they're spending their dollars, the technology that is certainly has to be used by the patient and family, what are the patients telling us in any model that we might develop and use? and so, a couple of years ago, we at the public policy institute at aarp conducted a national survey of both patients and family caregivers, asking -- and these were people with multiple chronic conditions who had experienced transitions, so that's the focus of this work. and we talked about what their experience was, what their concerns were, and just to cut to the chase, many of these patients, and caregivers, talked about poor communication. so as we're talking about technology, and the use of

patient self-management tools, many of them didn't know that they even existed. so here's some of the data i just wanted to share with you, that i see as the challenges for what, at the end of the day, we have to confront. which is, you know, one in four lack confidence in the health care system. they may love their doctor, or their nurse practitioner, but the system is very overwhelming to them. we know from other literature that the average person on medicare has two primary care physicians, and five specialists across four different practice settings. so, that's a little -- a lot to take on, and to have some confidence that this is all going to work together. 30% said that when they went to visit their doctor -- usually their doctor, that there wasn't enough information there to even have a conversation. family caregivers particularly felt that. 21% said that providers do not talk to each other. and this is where it really gets to be very tricky. so we talk about adherence.

how important it is that patients adhere to their medical regimen but they get conflicting information. one in four are saying they get different information from two or more clinicians, and that they feel their own health is suffering because of that. now this is the one that really got me when i saw this. 27% said they admitted this, this is an admission on a survey, where you know, usually you don't want to admit thing that you're doing and these folks are saying they had not done something recommended by a health care professional like get a prescription. so in other words they why nonadherent. most of them, 32% said they didn't agree with what was being told. now we need much more work. and maybe some in this room know that there's more work on this. i certainly want to drill down into this. but it's a serious problem. we know, for example, adherence, that more than 30 years of research that i've seen on community dwelling elders and prescriptions for them, about

25% of those prescriptions are inappropriate to begin with. and we know the polypharmacy is a huge deal. so my argument for years has been maybe it's a good thing that many of these people are nonadherent. they may be saving their own lives. so i really think whatever we do, we've got to be talking about this in a way that makes sense to people. we also don't talk -- i didn't hear anybody talk about health literacy, for example. and a few years ago that was really hot. i think we've got to come back to the hot health literacy issue. i remember one of the cases that i think it was a pfizer study that looked at this, was a woman who, isn't necessarily a chronic care condition, but a woman who was taking care of her child who had an ear infection. and kept coming back and the ear infection was getting worse and worse and was the liquid antibiotic, which she was putting in the ear. instead of the mouth. because nobody showed her -- she figured ear infection, you know, put the medication in that. we also know from the work on

hot spots, for example, in camden, that there was a gentleman there, many of you probably know this particular case, i think it's very telling, a person who -- a person with diabetes who kept coming back into the e.r., there was a certain pattern, and what's going on herein finally someone said well let me see you give your insulin. now why that wasn't done years before is beyond me. but, that's the nurse in me i suppose. but what he was doing was putting the syringe -- he had the bottle on the table, putting the syringe in and pulling up, instead of flipping the bottle, so in other words, in the beginning of the prescription he was probably getting the insulin he needed but as the insulin, you know, as he kept -- then he was just getting air and injecting air. so there was like a big revelation. well now we know how to manage this person's condition. so this, to me, is getting into a health work force issue. as well as health care delivery. are we getting participate tory guidance.

which used to be fundamental to the art and science of health care. we keep talking about the technology. but there's an art here, very deeply involved in communication. and culture. and outside of hospitals what goes on. we used to do anticipatory, you're going to find this is what's going to happen and when this happens this is what you should be doing. and we also used to do what was known as teach-back. so let me tell you how to do it. now show me how you're going to be doing it. these are really basic interventions, ken, when you're talking about. these are basic skills that seem to have been lost. we did a focus group with caregivers about a year ago, these were diverse caregivers and this is not uncommon, this is a gentleman, federal worker, pretty high level federal worker for a number of years, retired, went to take his mother home, he's the caregiver. went to take her home from the hospital and they said you're going to have to give these injections.

nobody showed him how to give an injection. he thought okay, i'm just going to go home. they were abdominal. must have been like heparin or something, right? so he goes home and starts giving this, bruising the whole body, not knowing what he's doing, and wound up taking her back to the hospital, in which case the health care team in the emergency room said, what have you been doing to your father? this is the experience of family caregivers. well, it might have been good if you show me how to do this. there's a lot going on, i think, with trying to get to that point where we're talking about confident, knowledgeable, skilled people who can be engaged, but they've got to better understand what's happening to themselves so that they can do it. >> well, with that, miraculously, we have ended this part of the program, almost exactly on time. so, let's take advantage of that and get started and go to our

break, and then we'll come back for a very vigorous discussion where we try to knit all these perspectives together, and get to some more discussion about actionable solutions. so, enjoy the coffee break. see you back here in 15 minutes. 10! okay. ten minutes. >> speaking of actionable facts, the rest rooms are in this corner, out the hall, and turn left. and please do get back in ten minutes so we can get this conversation started. >> and when this health care discussion continues, we'll hear from officials within the centers for medicare and medicaid services, aarp, and health care researchers. the alliance for health reform is looking into the causes of rising health care costs. the alliance was founded in 1991

by democratic senator jay rockefeller of west virginia. during this break we'll take a look at some earlier comments on how medical costs break down. >> there's the contrast to marcus well:. that is a proton beam their. chamber. it's:. that is a proton beam their. chamber. it. that is a proton beam their. chamber. itb. that is a proton beam their. chamber. ity. that is a proton beam their. chamber. it's somewhat controversial but one thing you can be sure about is, it's expensive. so you know, it's always interesting to know how these things work. here's a nice schematic. you can see that there are these various gantries to treat patients. the real power source, of course, is money. if we didn't have big demand for this kind of technology, we wouldn't spend the money. it's the money that drives the system.