decrease in the rate of cost growth. in this particular case, the second you take out and do the analysis on a closed group basis, so all you're doing is following the individuals that were with the employer in the plan prior to the change and then carry them through the first five years, you get a one-time shift down. similar to the old managed care shift. and then the cost rate actually is slightly higher than it is for the end quotes full population. so, we haven't been able to find other studies that have been making that closed group analysis process in it. so, there may be the appearance of good news out there that isn't quite as good, basically, vis-a-vis what is happening.

the second point i'd make, which goes a bit to what ken was talking about, and others on the chronic issue. and i'll flip to an article that -- a fairly thorough piece that was in "health affairs" with a much lengthier piece that then followed it in "the washington post," on lyme disease. and if you take the state of virginia, where when the current governor came in, he, for the first time, appointed a governor's task force, the governor's task force came up with recommendations. the governor said we shall enforce the recommendations. the state health department began an immediate process of sending out mailings, and creating educational requirements for all those licensed to practice in any way within the health system in the state of virginia and the rate

of test-positive reported cases of lyme in the state of virginia has skyrocketed. as it is also at cdc the highest rate of reported growth across 48 states at the moment. as it is becoming through health affairs, popular media, gubernatorial task forces. that is a disease that the infectious disease society treats as an acute disease. it can be easily cured, they say. and for those that think they have a chronic disease, who are in a wheelchair after treatment, who still can't chew after treatment, et cetera, these are all deemed to be non-lyme related and nontreatable. those that are told they have mls, chronic fatigue syndrome, et cetera. so this goes to the dual

eligibles, the medicaid, the medicare, one of the fastest rates of increase in granting a social security disability, and with it medicaid coverage, is, in fact, lyme disease individuals who, according to the infectious disease people, don't have lyme disease. but relative to the chronic conditions, do. so it's just to underline a number of the comments both on the treatment issues. on the analysis and diagnosis issues, and to the technology issue of testing, the fact that lyme testing, as the article in "health affairs" pointed out and elsewhere has been pointed out, is an extraordinarily ineffective, very high rate of false negatives test. and there's a tremendous need for advance in that area. but even with a lousy test it is

suddenly producing new costs that will push the cost growth curve as we move in this area. so the employer's side, joe, i agree with you. there has not been a tremendous movement. if one looks at the magnitude of that system towards a significant change. those that are making the shift to high deductible, and in essence thinking they found nirvana, when you cut the data, just looking at a constant population, nirvana still is a long ways off. but to the point raised by others, a one-time decrease of 17% before it starts going up again is not necessarily a bad thing. but then i'll add the final caveat.

hsas as established under federal law, the data is not owned by the employer. and, in fact, in most cases, only one of the insurance carriers is structuring their products so that they actually can do an analysis that includes what is being spent out of the health savings account. and even with them, because the law allows the employee to move the hsa provider bank and then there's no reporting back, is the vast majority of research to date excludes from analysis what is being spent out of health savings accounts, and treats that spending as not occurring. so, the data on that whole area is exceedingly dirty. >> comments, anybody? okay, let's see. i think michael barr is next. >> thanks susan, i'm going to go in a slightly different

direction if that's okay. it's been refreshing at least for me that we've been in a meeting about 2 1/2 hours on the role of technology and chronic conditions and nobody's mentioned the phrase "meaningful use, which is nice. but i'm about to change this. i have a question for the panel, and full disclosure i'm on the health i.t. policy committee and their four subgroups now working on different ideas through stage three. but i'm curious, from the panelists, whether they think stage one of the proposed objectives and measures for a stage two are moving in the right direction in terms of helping us to improve chronic conditions and managed costs. and whether you think so or not, what would you recommend for stage three? >> total interoperability. until you get that, you can throw out meaningful use and this, that and the other thing and say that. but until you have the different hr -- or ehrs speaking to each

other and the data being transmitted from the specialist to the primary care with two different systems, you can measure all you want. but it's not going to help us. it's still going to be inefficient for the practitioner. >> bruce? >> i guess the comment i would make is, so where is functional assessment in all of this? again, as a practicing physician i get the value of all the little data points we love to collect. but when you look at the population that both diane and i show data about, and when you reflect through on melanie's broader comments on her kind of current focus in the preduals, until we understand the role of function in both physical impairment and cognitive impairment, you can write prescriptions and stuff and you can do tests and stuff until the cows come home. but if you can't understand whether you can, you know, sort of thread that data set through the life of a fully built human

being, that's a real problem. and i see that as being totally missing. >> brad? >> in the spirit of specific recommendations to reduce cost, and connecting the dots, i want to follow up on something bruce has been saying. and that is the importance of functional impairment. it's not just because, you know, people when they can't function, utilize, it's that multiple chronic conditions plus functional impairment, those just happen to be two of the most powerful predictors we have for mortality. the bottom line really is, if you look at the population that has more than three chronic illness diagnoses and functional impairment, you're looking at people who are getting near the end of life. where spending is very high. we all know that in medicare, 28% of all medicare dollars go to patients in the last year of

life. 30% of that 28% is in the last month of patients' lives. and 80% of that is in the hospital. i thought the articles that were supplied today are really interesting. the amed news one, "who are the chronically costly health care's 1%?" this is the population that we're talking about. as ken mentioned death panel rhetoric has kind of paralyzed the debate on what to do about these folks. but i just want to suggest that the managed care approach of targeting costs, and thereby reducing utilization, there's a word for that, and it's rationing. and it's caused managed care to be torpedoed across the country and we saw what happened in one of the graphs we saw today. i would submit to you that targeting costs in order to reduce utilization in this

high-cost, vulnerable population is exactly a 180 opposite of the way we ought to be going. what we should be doing is looking at the word cloud, hospice. those of us that have done hospice for years know that you can be a day away from death and be very comfortable, very functional, believe it or not very happy, at home, all the words in the word cloud are fulfilled, and we can target those kinds of personal preferences in order to drive reduced utilization because a lot of these folks do not want to go back to the hospital. if you start with personal preference and then reduce costs, that's the right direction. and nobody's going to argue with that. except for those who just think personal choice is just a bad word. but out in the real word, what people want should be driving what they -- what kind of care they get. and we don't have mechanisms to

make that happen except in the few places where we've trained teams to be in the home and community to move the focus of care out of the hospital for this population, to where it needs to be, where the word cloud is fulfilled. i just want to put in a plug really -- and by the way, i'm a palliative care doc times 20 years, and i do not think palliative care by itself is the answer. because it's viewed by most physicians as an alternative to treatment. so it's either we treat, and when we're done treating we turn over to palliative care or hospice. that doesn't work. i can attest to that. you know, with decades of frustration. what does work is to train teams to see what people want and do both treatment and comfort care in a package. we can do that. and we are. i want to put in a plug for ctac, coalition to transform advanced care, which is here in d.c.

putting into process and measuring results on exactly what we're talking about. and i think next meeting it would be great to go into this in more depth because i do think it's a way forward. >> great. yep, please, jeff. >> i've been talking to students about shared decision-making, or some other name for it a long time, and i would write down on a black board a utility function and then everything flowed. and i just went with my wife to see a lawyer about redoing our wills. and so i got to thinking about what one would say in advanced directives. it's very hard. i mean we know from all sorts of studies that people are bad at complex decisions, which this is. they're bad at probableistic decisions, which this is. they're bad at emotional decisions, which this is.

i'd like to think i'm pretty good at that. but just trying to say, either orally or in writing to my wife or my children what i would want, there's such a vast range of circumstances looking forward that you know the simple kind of example we give people about the doctor said says, well, you have an x percent chance of survival, and by the way, here's what will happen, what kind of pain and suffering you'll go through, it isn't like that, and probably most doctors aren't very good at giving those kind of probabilities anyway. so while i'm kind of all for bringing in the patient, i'll have to turn into an economist if i wasn't, i think it's very, very hard to do this in practice and then pretend we've made a big advance. now that's not saying in some cases we clearly could do this. no doubt about that. but as one starts to push this and get close to it, i think it's hard. i'd be interested in what brad has to say about it.

>> if i could respond, you know, i have to say, joe, i agree completely with what you just said. as a doc in the office and the hospital and the icu, or talking with attorneys, a one-shot conversation on advanced care planning yields very little. i think if there's a secret to this, it's that as people get more and more ill within this period, where none of us, if you're sitting at the table, you're not this sick, okay. the people we're talking about couldn't be here. they can't even make it to their doctor's office or church. i mean, they're very ill. once you get that sick and move through your illness, if you have a trained team there helping you understand what the illness is about and helping you understand what your real options are, one of which is 911 when you lose your breath at 4:00 in the morning, there's

others, as well -- the interesting thing about the word cloud is that the people who are the most ill have the capacity to live just like the words in the cloud, but we teach them to come back to the hospital. we don't teach them to manage themselves, to see what their options are, and we don't put help for them in their homes. and i think that's why i think what you're saying leads us to the place where we have to do better care coordination in the community, and we have models and data showing that that works. because you can't do advance care planning when you're well. it is too complicated and you're not down the decision tree far enough to know what's going to happen. once you're that sick, you do know what's happening. and you've adapted, and that's when decisions, over time, with trained teams, make a difference. >> ken?

>> i know i mentioned this in my talk, but i guess just wanted to reiterate that i think we could do three simple things. they're not going to solve the problem. but, they are going to contribute to -- to the solution set. and they'd be inexpensive. so we're not looking at something that's a big, big set of expenditures. one is on this prevention side. as i talked about, you look at a prediabetic overweight adult at age 50, they have an 87% chance of having diabetes during their life. if you enroll them in this diabetes prevention program i just talked about, lifetime likelihood of getting diabetes is 62%. so, that's a program that we should just roll out nationally. and then, leverage medicare to refer patients into it. that's a program we could do for $80 million. that's less than 10% of the prevention in public health fund next year. so i would do that. i'd make it a covered benefit in medicare. doesn't have to be the dpp but something like that.

second, is that we have got to build on this base care coordination and to traditional fee for service medicare. it makes no sense that that's really the only payer that doesn't have any type of care coordination, and as we've heard, they own the chronically ill population. i mean, that's who they are. and so, we do know from a whole host of data, in the private sector, from randomized trials, functions that improve clinical outcomes and reduce costs. and i went through some of those like transitional care, health coaching. medication therapy management and so on. and there are evidence-based models across the board on those that we should just integrate into fee for service medicare. and the third thing that we could do is pay attention in the definition of the central health benefits for plans offering services in the exchanges about what do we mean by prevention and care coordination. we spent a lot of time on the other elements, defining what

in-patient care is and so on. we're spending no time really thinking through what do we expect plans to do in terms of preventive services, and i'm not talking about clinical preventive services, i'm really talking about disease aversion. and care coordination for plans and exchanges. i think that's a really important discussion to have with states, with health plans. because there's going to be an incredible amount of transition of patients from medicaid to private health plans within the exchanges. and i just think that that's something that at the state level we need to get on. that obviously in terms of cost, minimal. if any. but those are three things that we could do right now, i think, that would make a real important contribution to reducing hopefully both the leveling trends. >> ken, i just want to follow up on your point about prevention and the diabetes prevention program. because as you know, a large share of the long-term analyses of that program showed that, notwithstanding the fact that many people do lose that 5% to

7% of body weight, a very large share of them actually gain it back. there still is a benefit, as you said, in terms of at least delaying progression from pre-diabetes to diabetes or causing it to cease in some people, but it gets to this issue that i think has been put back on the table. turns out people do not operate in their best interests. we are now quite aware of a field of behavioral economics. and do we understand really enough about human behavior to know that these interventions are going to have a lasting effect? >> well, we know the two facts that i laid out in terms of the long-term likelihood of getting diabetes for somebody at age 50. again, we're sort of paralyzed here with not doing anything without having years of randomized trials. gosh. it's a good thing the private sector doesn't work that way but

medicare does. there is a ten-year followup with the dpp. and we know in the ten-year followup that, yes, there is some weight regain after year three or four. but that that just means that we should focus on what can we do in year three and four to reinforce it? i guess that's the first point. the second point, i say, so what? it still has a 34% cumulative reduction in the incidence of diabetes within a ten-year time period. so compared to doing nothing, we have 34% less. >> all right. so -- one of the elements on the table, clearly, adopt the diabetes prevention program -- $80 million a year? >> i'm not used to talking about ms, i'm used to talking about bs. talk about more. it sounds more attractive.

$80 million, yes. >> like to go back to dr. stewart's comments about end of life issues. i think one of the things in teaching residents that we forget to do is, we're teaching them the technology so they can start using technology, and what we don't teach them is just because we can use something, should we use something? that thought process. it's far easier to provide something in a setting of end of life or something like that without thinking than not doing it. one, you feel better because you're trying, even if it's a hopeless case. so i think this also gets to the point we mentioned a little bit about patient-centered medical home, and some of us talked at the break about that, is we need to look at understanding the use of the technology both by the primary care doc and by the specialist. and make sure there's a coordination in the use of that technology.

both in the setting of the first workup of the disease and also in the setting at the end of life. a lot of technologies used that really is not going to aid or help the patient in the diagnosis, the treatment or even in the comfort, like you presented. so i they one thing we haven't looked at or discussed is actually getting back into the teaching realm of the medical schools and the residencies and understanding -- getting them to understand the use of the technology better. >> and to get them to work as teams. i mean, as i look at any academic medical center a school of public health, medical school, nursing school, school of pharmacy, school of social work, they'll all see the same patient at some point during the course of that patient's treatment. but there isn't a structure that really gets them to work together to think about, how do we work collectively as a team to keep that patient either from getting the disease or healthy? >> i would add, there was an editorial i think in the "new york times" a couple months ago

that internal medicine has to get more like pediatrics. my training is pediatric cardiology. believe me, we had a social worker, pharmacologist, he knew how to pull up the, if giving drugs, how to do the bottle. they didn't leave the hospital until parents could give the meds, could give it appropriately. even if it cost the hospital an extra day and wasn't reimbursed, the patient didn't go home until the appointment was made and our appointment was made. >> bruce? >> maybe to dwell on that a little bit. i think about my limited health training when i was in medical school. it actually had a framework. that said there were three levels of prevention. there was primary prevention. and smo how, most of the discussions i'm involved in these days seem to focus on prevention in a very primary kind of way, which is all about preventing people from getting it. you know, care coordination is all about the other two kinds of preventions for people who are sick and possibly treatable and for people who are sick and treatable but not curable.

and so i think we need to get back to this notion that a really good care coordination plan is actually a form of prevention. it is a public health responsibility. and it's sort of missing -- i'm sorry to sound so energized but it's really missing from these discussions. at the end of the day i go back to the question what is the problem we're trying to solve here? at the end of the day, we have developed a tradition in late 20th century american medicine of introducing a pill or piece of equipment in place of a good discussion. and particularly in a situation when the outcome is functionally driven, not medically driven. you're not going to fix the fact this person has had a substantial stroke and is now hemi plegic. now you have to focus on quality of life. it's an issue at every level of the medical system. there isn't a good framework. understanding the person's medical and personal goals are, that we continually substitute

expensive -- potentially very risky therapies in place of a thoughtful and evolving care plan. when you are seriously ill or have substantial functional limitations, it's not a fixed point in time discussion. it's like a mosaic that evolves. you have to be willing to pull some tiles out and change it around when the image changes. there's a knowledge laer discussion about how to use technology and the notion of this really thoughtful care plan that's revisiting over and over and over again. my one fear about the fee for service medicare is we get a code for a care coordination and a follow-up and it won't work, it just won't. an intensity in this intervention that's important and goes back to the fundamentals of public health. okay, i'm off the soapbox. >> could i add to that very quickly. in the interests of actionable steps, there's been a lot of talk about what's effective care, how do we change medical

culture? how do we teach residents? our experience, i think, in a big 24-hospital system is the way to change medical culture is to change the structure of how the care is provided. i have to say as a doctor that i don't think doctors are the answer. you know. there aren't enough of us to go around. with the gray wave that's about to inundate us. the teamwork that we need are teams of other professionals that can work with us to extend our care to people who need it. the kind of people bruce is talking about. and i think there are models out there that provide that kind of care coordination. we have data that show that it works. that simple change in the structure of how care is provided, just reengineering the system in that way, would really equip us to do a lot of the things we're talking about in that way.

doctors want to care for the people who can't make it into their offices anyway. they're too ill. >> we have some more cards up so let's go around the room this way. david, and work our way around. >> follow-up to the last couple of comments. question really for ken or melanie or anybody else. on the issue of care coordination, team-delivered care, it doesn't -- you know, i think the common wisdom now is that this is really an important way to get at this high-cost population. but at the same time, it doesn't seem to be as simple as simply adding on a paid benefit. it seems to require both a structural change and a cultural change for a lot of care-givers. i wonder how we go about doing that in a program like medicare or medicaid for that matter? >> you're right, and it's not a coding change. i sort of think about it the way that north carolina, vermont have gone about this. in terms of building health teams that work with primary care practices. and the way i think you could do

it in the medicare program, and i would do it in conjunction, too, with the exchanges, is basically that you would have to contract out, like they do in vermont, with different entities and different planned service areas, to have teams available to work with medicare patients. i would start off with them being voluntary. i mean, the primary care practices don't have to use them. but our experience in looking at them in vermont is that they all do. because i think that bruce, brad's point is that they are a natural extension of the office. they engage and work with the patients. they help them make sure they understand the care plan. the care plan is executed. they have questions about the care plan. they know where to go. they're nurses, nurse practitioners, pharmacists. they're doing all the blocking and tackling and execution of the plans. and they're not physician-led, they're nurse-led. so i think you could very easily have medicare build these teams

and have them available for others to use. if medicaid in the state wanted to do it, that would be fine. a lot of states are doing this. and there's a section 2703 in the affordable care act that gives states an enhanced 90% match to put these teams into place for two years. so i think in combination with that and medicare, maybe through the innovation center, which i know they're doing some of this, that would be a way to start building capacity into the program. and you'd expect them to do some of the functions i just talked about. 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?