that and medicare, maybe through innovation center, which i know they're doing some of this, that would be a way to start building the capacity into the program, and you'd expect them to do some of. functions i just talked ak. expect them to do the functional assessments. expect them to do some of the social functions. the medication therapy. transitional care coaching. work with them on health literacy issues. so we have experience in vermont. they do this with medicare patients. in fact, the teams are used to manage all the patients in the provider practice. so the challenge we have is that like any type of care coordination program, it requires an initial investment. all right? so unless we're going to invest in it, we can't get any of the health, the health care benefits and you can't get any of the, any of the savings. i would hope through a combination of some innovation money we could start this going.

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

what you can do is provide incentives for health plans to use common sense, but -- >> right. >> -- it's only been 45 years so far. we'll see. >> going to keep working our way this way, and i'll come back around. carmella, we'll catch you up next, but i promised people -- forgive me, but you're so far away. i cannot even read name cards down at that end. >> not a problem. peter bowers with well point. i appreciate this opportunity to speak briefly and you know, my day job is payment redesign across our 14 blue plans. we cover one in nine americans across total blue, almost 100 million lives and a number of different levels we're using to change sort of this fee for service reimbursement. we've got to change the system that people are getting care in. and all of the things discussed, patient preference, very important, supporting physicians with data. i.t. will help with inner

operability. weren't of the levels, there are multiple levels we need to create, i'd like to talk attention to touching on chronic care and technology. something that crossed all blue plans. 100 million lives support this from a data perspective. the comparison tools look at at over 200 commodity, colonoscopy. catter racts, total cost for members, door to door, includes everything associated. pro fee, facility, anesthesia and very informative. colonoscopy, for example, heaven forbid, joe, you need an images this afternoon, all images for sciatica is on there as well. you can be smart where you spend your health care dollars. and this tool is really important, because i think as we think about moving forward the amount of information that flows to help you make better informed it choices is coming in here. so appreciate the moment. >> great. thank you. so we'll keep moving this way.

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

susan's chart actually showed that. that people don't adhere to the kinds of treatment regiments that's they're recommended. and instead, we end up costing the system more. if we can prevent hospitalizations, if we can prevent readmissions because we've included that patient and that caregiver in the design of that care plan or management, that's a good, actionable step. >> henry claypool of brown hhhs with the add mip strags for community living. secretary sebelius just recently formed at the department and a couple of points. the point about really beginning a dialogue with an individual about what their future is going to be like when living with a certain condition or towards the end of their life, there's a whole population of individuals living in the community today with functional need, and i

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

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

care transitions grants. we're still making grants at hhs, to organizations prepared to do this, but we really know they're underdeveloped. and so through policymakers in the future, looking at making investments isn't something like what the secretary has created in the administration for community living really might be a sensible alternative to trying to continue to do this through a rigidly structured medical program that is in1r06volved in political dynamic thoroughly discussed here today. >> enrique? >> thanks. enrique martinez from the academy health, director of the robert wood johnson state coverage initiatives program and ran the state quality improvement institute for several years. the commonwealth funded where we worked with eight states upon quality improvement delivery reform and a few more examples what states are doing out there.

ken talked about vermont and i'll add a point or two of that, but under our state quality improvement institute states really wanted to focus on how to deal with costs. they called it quality improvement but it was really how do we deal with costs? if you think medicare has problems cutting, reimbursement and cutting services, that's what medicaid does and they've sort of tapped that out at this point. to the end of the rope with that and they're turning to another way to do this. care coordinations is a huge thing. delivery system reform, payment reform. a lot of states out there doing primary care medical homes trying to even get to acos in terms of medicaid. colorado's doing it, new jersey's doing it. oregon, aalities more detail as well, a little vision at this point, but they're really thinking broadly. consumer engagement is a huge piece of that. not only financial incentives, also the education piece, susan was talking about.

health literacy was a big piece as well as sort of the wellness programs and how you do that sort of ahead's time. how do you stop the costs from even occurring. health information technology was a huge underpinning aspect to this bringing all the sort of, how do you, inner operable aspects that was critical and the met tricks. accountability for having this all. sort of the overall package of work that we had done in a number of these states. vermont, as ken laid out, community health teams cass s w visionary expect a all built around the medical homeses. they're still trying to figure how to get to sort of the next layer out with specialists and hospitals, but they also had health information technology that underpirned the whole thing, retch strifs, electronic health records and accountability metrics and for outcomes. the other just one last point. what oregon is trying to doing

with their coordinated care organizations, is a bit of a vision but they've gotten a cmk waiver to implement this. it's a huge undertaking. it's going to be medicaid, state employees, their high-risk pool c.h.i.p. and hoping to bring in exchanges when they get up and running to integratened coordinate benefits and services. local accountability for health and resource allocation. standards for safe and effective care and a global budget. that's indexed to sustainable growth. they have a website that explains all that. i would recommend that people go and look at the coordinated care organizations that oregon is putting together. just a few examples of sort of real work on the ground. >> thank you. diane? >> i just wanted to go back a little bit to where brad was about people ending up in the hospital in the last year of life and right in the last months. and sometimes we learn from research and sometimes we learn from personal experience, and

we've talked a lot about the coordination of care, which is basically in a community, but ooo-ey thi ooo-a there's a different xwags. my mom had a really good coordination team in the community and then she ended up in a hospital to be treated for dehydrationened then she ended up in the hospital longer and longer, and the hospital ichts took over and i couldn't get anyone to answer any of my questions and the hospitalists kept turning over and turning over and i think finally i just got her discharged and brought her back home, but i think that we can talk a lot about coordination of care when they're not in a hospital, were ut we need to also be looking at the whole trend in the hospital, towards hospitalists and what that means for the ability for the care to the managed. >> thank you. susan? >> yes. i also wanted to mention around this interprofessional collaboration which is the foundation of care coordination and the infrastructure being

mentioned down there. there are some things that are happening and some of this can be pushed from the public side and some of it is being pushed from the private side. so on the private side you have foundations like the commonwealth fund, for example that has done work on the mary nail around tkomen but trying t get people trained in it. people all right out there, not just new students, which is critical. and other tremendous work. aarp working on future of medicine, future of nursing work with a high, high priority on interprofessional collaboration. we have 49 states with action coalitions many of which are making thas high priority, across the state, across different disciplines. it's very, very challenging. we fwhknow there's been efforts before to do this but you also

have hersea for funding of ode educations to intereducation collaboration. lots of different things that are efforts in place that i think we should all be trying to reinforce, because it's got to be done from the ground up and we have to change the culture among the existing professionals. >> great. thank you. bob helms? >> okay. one of the major topics today is technology, but i've heard very little discussion about the process of innovation. i think we all sort of believe in, want to the think there's possibilities for improvement in innovation and technology. but a lot of the literature over the years has complained with a system both private and public nominated by fee for service that the incentives are more sort of cost increasing innovation as opposed to cost decreasing or value seeking innovation. so my question to the panel is

sort of, is this distinction important? and is, as long as we stay with, in medicare and the private sector a system dominated by fee for service, how do you get this sort of change in incentives for innovation into the system? >> joe? either joe. >> this joe? >> you first. >> sorry. i -- i was waiting for joe. obviously, incentives are important. i think there's an issue about, from the public financing or even the private financing point of view about how, who gets those savings, assuming there's innovation and savings occur. so june says there has to be incentives for the provider. i'm somewhat concerned about

market, increased market power providers, that they may appropriate most if not all the incentives. or savings. i should say. but that's obviously speculative. so yes, i mean, i think as risk gets pushed out towards providers, and i believe that some -- that should occur to some degree, that would increase incentives for providers to demand saving innovation, but then who gets the savings? >> okay. brad and then carmella and then we will wrap up. >> a couple of points. around care cordonatiordination about it but assume we're talking about coordinating care across space. geographically across settings. do diane's point.

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

coordinating care across time, and both of those have to happen. and, again, there are models there that do that. now, the second point is financing. again, back to joe. shared risk, shared savings probably is where we're going to end up. we have to have providers sharing risk with payers, and with medicare. but you can't just jump over to get there, because we're in the fee for service world, and it doesn't -- you can't just go from here to there. we're paying $20 million a year ourselves to put these teams in place in order to save medicare $2,000 per month, per patient. now, we're willing to make that investment, because we know we'll get, at some point, to shared risk and shared savings, and we're talking with cmmi about doing that, but the little providers out there that aren't integrated systems can't possibly do that.

and nobody, not everyone's going to become an aco. so our proposal would be, use these across space and time care coordination teams to allow independent providers, hospitals, medical groups, home care agency, to become virtually acos and i'd make that as a specific actual proposal and then create interrum financing to help people over the bridge to slayered risk, shared savings. that's exactly what cms wants to do and there's got to be a way to pay for quality on the way. so, yes, you get paid for now, but you can't game the system. you have to make outcomes in order to get reimbursed. so -- that's going to take a lot talking, but a concrete way to accomplish it. >> carmella, give you the last word. >> so my comment actually goes back to the proposal that ken put on the, the plea ken put on the table about, you know,

prevention and diabetic care and unfortunately i have to agree with joann. medicare is just this 800-pound gorilla that isn't flexible and didn't move like that and they try to create programs, one size fits all. this is not about one size fits all. as we've looked at what goes on in the private sector, we have a lot of physicians in this country that are in one and two doctor offices. they're going to have very different needs and have different infrahm structure tst need pop build than those in ins grated infrap sturs. every time we have the debate we kind of forget about them. i'm very worry and them because they need certain support if the they're not going to become a group and actually survive in this whole new environment, and i also think we have to think of primary care very differently than specialty care. i found it really interesting this was a meeting about

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

coordination and care transition across the continuum of health care is extremely important, but when i think of technology, my radar goes to specialists, not to primary care. >> let me -- let me -- i'm going to rebut you here carmella. >> i'm sure you are. >> 30% of the eck 0 es we read, i read at children's hospital were ordered by the primary care doc. they had zero yield. none were needed. and i'll refer you to the pilot program we did with nuclear studies down in ten house, ten settings. yes, specialties order more tests, because we have, that's part and parcel of the modern stethoscope, as joe mentioned. at the same time, if you look at the inappropriate rate of the specialist versus the inappropriate ordering rate of the primary care doc, which accounts for about 30% of tests being ordered, it's 50% to 60% for the primary care doc and

they don't need the test at all. they're trying to figure out what's going on with the patient, and they order the test, because they don't know what's going on with the patient. the specialist order rsz the test in a patient who already has the disease to make a decision and they're inappropriate rate is doing it too often. it isn't doing it to someone who has the study. so it's a, two different aspects of the testing, and, again, you can get about a 30% reduction on unneeded, completely unneeded testing by just having the primary care doc call the specialist and say, you know, what's wrong with this patient? do i need to do this? that's what our focus tool actually does. the tool sits on the electronic record and looks and says, is this an appropriate study or not? if the primary care doc soaredering the test, call the cardiology instead of ordering the steft. >> maybe just to respond in a similar fashion. you know, i actually wonder

about the comment, too. you just crystallize what i view as a internist as one of the single biggest problem, which is, this highly -- actually goes to the example, diane, that you gave, this highly fractured medical system where there's a plan of care and a primary care. plan of care and specialty care. this sort of fractured patient center but only through one lens of the parent. are you an out patient, in-patient, that's the problem. you just crystallized the problem. the idea there would be a gulf between the primary care, the specialist, the in-parent system and frankly all the community-based providers including the family which we've not even talk and much today other than one very important comment earlier. and at the end of the day, sort of the failure of all the medical specialties to delegate appropriately except whpt we plan to make the family responsible with almost no training i would go back to the floegs should be a care coordination plan that is

person-centered, not patient-centered, particularly when talking about somebody who's chronically ill and functionally limited. as long as we have these we'll have a problem. maybe that's a place to close on. care kworden sags in essence a technology we don't really know how to use very well. we all have examples, getting that role out could be important. >> well, thank you all for a terrific and vigorous discussion. i would note that depending on whether you are a glass half full or glass half empty type of person, you heard a lot here that will send you one way or the other. [ laughter ] i will say what i heard was, we do have a lot of solutions, actionable solutions. frankly most are being tried. maybe it's a case of more, better, faster, but most of them are being tried. we heard about the increased

need for end of life, better end of life care, ender life engagement. just a quick commercial for health affairs, our june issue is devoted to a range of issues across what we call the care span, thanks to support from scan foundation. please read a piece by bruce about dignity-driven decision-making, which i think is precisely what brad stewart and others have been talking about today as a prospect for really making headway on in a issue. we heard a lot about care coordination. we know a lot of these efforts are already getting underway or are under way. we heard about the role of new, newly trained and empowered types of providers. ken brought up community health teams working in vermont and elsewhere. we heard about the, the known successful interventions around the diabetes prevention program, the transitional care program, et cetera. that clearly is a case of more, better, faster, because we know these work. we simply have to adopt them and put them to better use. we heard about the role of patient and family engagement.

again, clear evidence in the research that if you really engage patients or as we otherwise call them people in their care decisions, they get better care and they're happier with the outcomes. we didn't spend as much time on some of the things that were on joe's list but we know those are out there. those are changes in private insurance, whether it's move to select to the provider networks, value based insurance design, et cetera. joe, we completely left you alone on the notion of premium support and medicare as being one potential. maybe that's for our next session, but i think, again, just to close, we have a lot of evidence here that we have tools that work. and, again, if you're a glass half empty person, we're not going it enough. if you're a glass half full, at least wee trying. so there's a lot of perspective here for some additional in-roads to be made in whether,

again, it's the level or the rate of growth we can, we have some evidence we can make a difference. so with that, let me turn things over to ed. i think you're going to say a word or two about the next install innocent this series. >> yes, thank you susan. we are -- we are going to start talking about solutions. we talked a bit about solutions today. but we knew that we needed to tap your brains on that aspect of it as well. june 12th, which someone pointed out to me is a tuesday, not a wednesday, we'll be convening the third and last briefing in this series in this space, but not in this time. we're going to start with a lunch and go to a reception, which we'll note the fact that this series is supposed to mark 20 years of activity by the alliance for health reform. so i guess we can take credit

for the condition over the last 20 years. [ laughter ] let me just quickly thank our sponsors, our hosts, and most particularly, our panelists and speakers for an incredibly good discussion, i think, of an incredibly difficult topic. [ applause ] and before i let you go, could you, please, as you rise and collect your things, pull the blue evaluation form out of packets and and give us some feedback, and particularly, give us some notions of what we might do next, following the wrap-up session in june, to try to contribute to the dialogue that could get us some progress on controlling health care costs. once again, thank you all for coming, and we'll look forward to seeing you next time. bye.