with individuals who were 45 to 65 and really in a caregiving role and those were kind of 65-plus who were caregiving or care receiving. this represents a word cloud that represents the language of what most folks used. and these are all individuals who could exquisitely describe either the caregiving 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 would offer to you there's very little medical stuff on this slide. and with all due respect to a lot of the great programs we have built, you don't see this riddled with disease management, palliative care, hospice. i kind of goes back 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 the technology fit, so why is this a technology talk? i want to -- i want to leave you with a few points. i think the points really are, you have to really ask what's the problem that we're trying to solve here? so there's very little evidence, picking up on one of the earlier points that surgical robots add much value. so the reality is that surgical robots at least at this point in time for the data that's available, solve a marketing problem for hospitals. if you're in a competitive environment it's good to say you have a robot and my friends who are surgeons love them. it is keeping your medical staff intact that -- that is a different problem. solving a marketing problem is way different than solving a clinical care or care coordination problem. so when we start to look at the 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 may be that it's more of a low-tech solver. what's the role of the telephone and the pieces of technology that do work and there's evidence? so remote patient monitoring. those are places where a little bit of technology, a small investment, can go a long way. that's take home number one. if we're going to introduce technology, what is the problem we're trying to solve with it? in the environment that diane described and that i'm trying to build on, technology is not an end to end solution. okay, technology rarely solves any problems in the seriously chronically ill, it is a tactic, not a strategy. so at the end of the day to introduce a piece of technology is going to get you nothing but costs and maybe more risks than benefits. most older individuals when they get sent home from a complicated

hospital stay, they get technology. the m.e. provider drops something off and if there isn't a plan there whether driven by the family or whatever, it may bring more risk than benefit so 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 as which think of the work you're doing, melanie n the care coordination office it's not just about the medicare model of care in the sort of nice model of care way we like to think about it. it's the model of care coordination and person-centered care coordination that is going to be at issue here. so as you look at the states who are proposing, you know, we would really encourage you to look hard at not just is there a plan for the pills and the this and that and the ins and outs, but what is the plan that

supports people's control with the function that they have, even if they have serious illness or a functional loss. and picking up on the comments in the audience, targeting is really, really important. you're not going to solve -- again, i think diane's slides really hint at this. for the high-spending medicare population, you know, medically oriented are probably going to take you a long way and so the nice article that was published in health affairs that covered some of the data sort of make the observe. that's a place where a medical home may make a lot of sense. because you have folks with lots of doctors and nurses and pharmacists and others. kind of coordinating the medical cats is half the battle that's a good place to start. but for the medicaid population where the needs are more functional or community based, the medical home may not be the solution because the problem with the medical home, you know,

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

great job in all of his 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 and any model that we might develop and use. and so a couple of years ago, we at the public policy institute conducted a national survey of both patients and family caregivers. these are people with multiple chronic conditions who had experience 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 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 -- usually the doctor that there wasn't enough information there to even have a conversation. family caregivers particularly felt that. 21% said that the providers do

not talk to each other. this is where it 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 saying they get different information and they feel their own health is suffering because of that. now, this is the one that really got me when i saw this. you know, 27% said they admitted this. this is an admission on a survey where you know usually you don't want to admit things that you're doing. these folks are saying they had not done something that was recommended by a health care profession. they were nonadherent. most of them, 32% said they didn't agree with what was being told. now, we need much more work, maybe some in this room know if there's more work on this. i want to drill down on this. but it's a serious problem. we know for example adherence that more than 30 years of research that i have seen on community dwelling elders and prescriptions for them about 25%

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

we also know know from the work on hot spots for example in camden that there was a gentleman, many of you know this particular case. i think it's very telling. a person -- a person with diabetes who kept coming back into the e.r., that there was a certain pattern. finally, someone said, well, let me see you give you your insulin. why that wasn't done earlier, but that's the nurse in me. he was putting the syringe into the bottle and pulling up. instead of flipping the bottle. in order n the beginning of the prescription he was probably getting the insulin he needed. but then he was just getting air and injecting air. so it was 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 giving anticipatory

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. so we used to do anticipatory, like you're going to find this is going to happen and what this happens this is what you should be doing. we also used to do teach-back. let me tell you how to do it, now show me how you're going to do it. these are basic interventions, ken, we're talking -- these are basic skills that seem to have been lost. we did focus group with caregivers about a year ago. these were diverse caregivers. this is not uncommon. this is a gentleman, federal worker. pretty high level federal workers, retired. went to take his mother home. he's a caregiver. went to take her home from the hospital and they said you'll have to give these injections.

nobody showed him how to give an injection. he thought, okay, i'll go home. they were abdominal, must have been heparin or something. 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 and 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 showed me how to do this. so there's a lot going on with trying to get to that point where we're talking about confident, knowledgeable, skilled people who can be engaged, but they have 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 the perspectives together and get to some more discussion about actionable solutions. see you back here in 15 minutes. >> 10. >> ten minutes. >> and speaking of actionable facts, the restrooms are in this corner. up the hall and turn left. and please do get back in ten minutes so we can get these conversations started again.

well, welcome back, everybody. we' we're now going to move ahead and engage in some brisk discussion, exchange of views. hopefully again, gravitation towards some actionable solutions that could make a difference in the rate of health costs, health spending growth and still get us the other things that we want out of health care. so just to briefly recap what we have heard so far this morning, first of all, we heard from jo antos that technology is a factor both in the supply of and demand for it. there has been some discussion about whether technology can directly be measured as a contributor to health costs. often it's not and it's treated as he said as a residual. it's the i don't know factor. if i can't explain it by oth other -- four other reasons, i call it technology.

nonetheless, as he pointed out, we can clearly see the role of technology. he gave a number of the historical examples of how technology has evolved over time. he offered a list of some -- a menu of some options, some of which he thought had some possible workability attached to them and others of which he was a lileas compare and effectiveness research. notwithstanding there's a lot we can do even within some of the constraints that exist, for example, in terms of medical program. he mentioned coverage with evidence development. notwithstanding the fact that medicare is as he said a political program. some of these changes could be made or could -- or some of these tools could be used more effectively than they are now and that at least there is some

prospect of reining in some aspect of technology growth that we don't want or need. then we heard from ken thorpe about how it now looks as if 60% of the spending growth over the last couple of decades has been attributable to the growing treated prevalence of chronic disease. much of this as he said is driven by rising obesity, whether it's diabetes or oth other -- or cardiovascular disease or other diseases linked to diabetes. and he spent a good amount of time talking about the problems that we have encountered with respect to these populations, lack of care coordination, lack of use of interventions that we know work. he mentioned the diabetes prevention program and the substantial evidence we have that loss of 5% to 7% of body weight can halt prediabetes to diabetes and really as he said should be a low-cost intervention that could be rolled out rather broadly. that, plus care coordination in many respects he mentioned as a

real force that could arrest some of the health spending growth that has been attributed to those causes. we then heard from our reactors in sequence. melanie talking about the purview of the poster children for the mix of technology and cost. we heard about a number of the pilots that cms has underway now to look for ways to improve the care of those individuals, decrease the churn back and forth between hospitals and nursing homes, et cetera. and reduce rate of costs there. we heard from joe newhouse that the problem of rising growth in health spending, those growth rates is really a problem that is ubiquitous across the world, and that notwithstanding the fact that the u.s. has a higher level, the real issue than the

other countries t real issue is this rate of growth or cost. how, as he mentioned, nothing grows to the sky. joe, i was reminded of the things that cannot go on forever will stop. and you mentioned that we are probably going to halt this dramatic rates of growth in health spending. you don't know exactly how, we'd love to hear you perhaps address if we near the midst of that stopping now with consumer directed health plans and high deductible health plans and people not being able to afford care and all the other factors currently. we heard from jim fasules about the beneficial aspects of a lot of the technology that we have adopted. with respect to cardiovascular disease, particularly as evident in the 30% reduction in mortality. from cardiovascular disease just in the last decade. nonetheless, as he pointed out

there are things going on in ca cardiovascular care that shouldn't be done and then there's the five interventions not to allow your physician to suggest that you have. and as he noted, that coupled with a lot of quality improvement, efforts underway at various institutions we're improving the cardiovascular care and perhaps reducing some of the unnecessary care driven by certain technologies. we heard from diane roland about the very important fact that the high spenders in the medicare program are different from the medicaid program. which is a recipe for us to developing a much more nuanced understanding about how to restrain excess cost in those two pockets of the population. we heard from bruce chernof again much on that same theme that half of the medicare enrollee with chronic conditions

have functional limitations. and half of them are dual eligibles but half are not. not. and we have to be mindful, he said, of the problem we're trying to solve. the problem as many patients see it, that they lack all of those words he put up in his wonderful word cloud. they're not spending a lot of time thinking about how to get access to surgical robots, they're spending more time thinking about how to have independent, dignified existence independent of as many health care providers as possible, very often. and then we heard from susan rinehart that patients and caregivers sense that a lot of the issues that they face in health care is due to factors such as poor communication, they don't feel that they are empowered sufficiently often to make decisions with their health care providers. they're also clearly lacking in health literacy.

she gave a number of examples underscoring that. and that they too would very much like to engage in much more constructive dialogue with their health care providers approximate how to have the care systems that they really want and that deliver on some of those wonderful words that bruce mentioned in his word cloud. so with that, the floor is open now for greater discussion about how we move forward, knit some of these issues together, and continue to work on actionable solutions to press forward. joe, did you want to answer the question i just briefly tossed out at you before we get going? >> sure. well, i would distinguish again between the level of costs, growth rate of costs, the phase

that was fashionable awhile back but i haven't heard lately, the curve on growth rates. so there's a lot of evidence that higher cost-sharing through direct health plans will reduce the level. not much evidence, if any, about growth rates. there's some evidence that the supply side interventions we're throwing out there will affect levels. they could affect growth rates. i could make a theoretical case they will. i don't think there's much evidence on that. so, i don't want to make that sound terribly negative, because at a minimum, even if one just changes the level, it buys time. and frees up resources for other activities. but, since i think the growth rate is the issue, exactly how to attack the growth rate i think we're still doing a lot of trial and error. >> okay.

>> that will be fodder for future affairs articles. >> yes, indeed. david. >> just, sort of follow up on your question to joe, i mean i do think that understanding the differences between society, it's really interesting to know that we have far and away the highest actual level, but a growth rate that's similar to other societies. but in terms of a policy prescription i'm not sure that there's quite as clear a dichotomy. if you can knock 1% off the level, for example, by reducing chronic disease or improving care coordination for the next 20 years, you know, 1% a year, then you've cut the growth rate essentially 1% for the next 20 years, as well. so i'm not sure that from a policy point of view, that distinction is as entirely important as it may be in terms of a scientific or understanding the differences point of view. >> i agree with that. that's what i meant by buying time when i said i agreed with the prescriptions that ken had put out about interventions. it's certainly worthwhile.

but, i think it's a -- the framework is to think about what interventions would change the rate of growth. it's not really something that -- advice not to do something that we know will change the level. >> yes, julie? >> corey from the american academy of actuaries. so, we talked a little bit about this last month when we held this and this was something we actually talked about in our medical technical panel meetings, this level versus growth issue, and we might be asking too much to say that something has a permanent long-term reduction in growth, and thinking more along the lines of, well, there's going to be a series of shorter-term reductions that then taken together will bend the curve.

so, you know, thinking about, you know, we can't expect one thing to have a permanent, long-term, you know, change in things. and so, how do we think about constantly evolving, and moving forward with new changes over time? >> is that stu? >> let me go a little further than david and corey just went. i'm not sure there's really a real distinction at all between level and growth rate. because to say there is means there's some kind of mechanism that generates a growth rate in health spending. and i'm not sure there is. i think a growth in health spending just means a change in the level from one year to the next. so if you go back to what don burrwick's been talking about lately, these wedges, then what you get, what increases health

spending is a bunch of decisions that are made every day and then they get made again the next day, and the next day, and the next day. so there's not really a process that you can identify to kind of target the growth rate separately from the level of health spending. you need to look at the level of health spending and address what's in there that you can then kind of not have more of unnecessarily. so, i'm not sure that it leads us to a productive set of policies to try to separate those two things too much. >> actually, i think there are mechanisms, but the point i think -- the reason to distinguish level and growth is that once you've gotten out inefficiencies and waste, you've done it. then you're back with some steady state rate of growth. so yes, to david's point and to your point, i could save 1% a year.

but for example, i could do that by raising a deductible. but at some point it gets ridiculous. it doesn't serve the purpose of risk-sharing. or i could do it by putting more risk on providers, but once i've got a maximal risk on providers, i've done that. the two colleagues -- my two colleagues at cms and i published a piece that's in your book on mechanisms to go to stewart's point on mechanisms, and we talked about income changes over time. which are certainly common across the developed countries. and we -- this goes partly to joe antos' talk, we thought that accounted for 29% to 43% of the change in growth. and we thought that interacted with technology, again, to go to joe antos' point, and that interaction was another 27% to 49%.

the insurance changes mattered less. i do think there's some in our data. we're looking now across the oacd and the demographic changes matter just a little bit. so, it -- and now chronic diseases, to go to ken's point, are also increasing, i think, throughout the developed world. certainly diabetes is increasing throughout. so that in, i think, going forward, that's also going to be driving cost, as he said. but again, i think all of these things are different aspects of the same reality. and i do think there is a mechanism that's driving the growth rates. >> i think dallas salisbury had a hand up. >> just a quick follow-on that set of points is, in work that paul friedsten's been doing with

the database that we now have had seven years of data pre and post-design change by a major employer. this goes both to joe's point that it makes sense, and joe antos' point that this is where there is some end quote freedom of innovation. the most common change on the private side over the last five years has been moving to far more shifting to an individual, high deductible, hsa, hra, et cetera. this particular company did all of that. it produced a -- when one does the analysis and allows the analysis to have all of the new entrants flow in, which based on looking at the literature is the way most of the analysis by insurers and others has been doing it, then you see a -- not only an initial decrease in cost, but what appears to be a