>> the first part is the long range concern that the international community has that iran is stepping away from the obligations to be a nonnuclear weapon state under the treaty. it said that the program it pursued to put in place, nuclear power reactor to develop their own indigenous enrichment capability, all of that is to produce nuclear fuel for the power program and yet over the years, we have seen many, many

hints that in fact there could be a military aspect to this program. the fact that assuage international concerns about possible military uses of technology that the iranians have been developing ask they have been sending inspection teams in 20 check up on all

aspects of the program. china and germany is the plus one. a big group on our side. their issues have to do with really trying to get a handle on these big visible signs that iran may be heading towards a military program. i talked about enrichment capacity and trying to get the enrichment capacity shrunk way down and looking at the heavy water reactor that they have been using to produce nuclear

weapons. lots of questions of those kinds. it's not a negotiation i'm in charge of, but it has been run by sec ter kerry has wrestled with the negotiation. and there a lot of heavy hitters trying to get progress. the big of heavy lifting is on the political side. will they take the political decisions to bring the negotiation home. we will see how it goes. we have a month or so, but it is an urgent time. >> i have been getting the hook

here, but i would like you to have the last word and the question is can we get a deal? >> i certainly hope we will have a deal. at the current time when we have the ukrainian crisis on with much tensions and that is going on, we need one victory.

when komeny came to power you fuelled for that reactor. the u.s. government stopped it. they didn't deliver the fuel. i don't think we got the money and they had a great time to find fuel to buy it and argentina. we better be self-sufficient. i think that's a weak argument.

the the element is that of pride. that's the story they never forget. the occupation of the american embassy. here are the motions that are deeply engained and they have to come out through practical action. i think they will. that what was reached in the summer is one that under which the iranians stopped producing uranium above 5% and they did produce and going down to the level which was needed. staying at that is a good thing. the other is the international inspection. it will be a very, very good inspection. very intrusive inspection and they will be able to take that

on the protocol that i have created. the issue i approached about independence and credible international verification. if they kick up, they can do that. that would be a warning signal. i think that will be enough. some will neve be satisfied. i don't think that's very likely to happen and they will not have the support of the assembly and the public opinion will not support it. they feel many of them going for nuclear power is a question of pride and their right and they don't want to be held back. >> thank you very much for your insight. thank you all.

the focus to the most important pressing issues is an honor to those of us who served and for those of us who have not served. but thank you. let me end on one quick note. this program you have been involved in on the state department is in charge of the funding is the best return on investment that i think the state department has. it is a phenomenal program and something that i think the country benefits. thank you for what you all did to be part of that. thank you all for coming and thank the panels. let's give them a round of applause.

>> i was told at 9:40. two questions. two questions. questions, please. >> this question this question is directed. this question is directed towards all of you. i agree with you indeed. there is a fear factor since the incident in 1986. do you not think perhaps much of the propaganda that circulated at that time and continued and instilling fear in the west as well as the neighboring countries on the border of the wall or the division between the east and the west. a lot has to do with the

literature. it impacted and he tends to focus on different types of film. the femme fatal. they focused on the fear factor of nuclear weapons and warfare. how can we deter the fear that we have towards nuclear energy? i am a proponent and a supporter of of. >> we will stop it very quickly. >> thank you very much. i think you are right. what is the root cause of the opposition and fear. i think you have to relate and they are geared to warn us.

we are worried about it. we should be aware to have the instruments that we pick up very easily. we know we rely on the sunshine, but if we stay there long, it's dangerous. the same thing with others. it's high concentrated. it could not be enough. they talked about the ap 1,000. a new type of the reactor.

it's a small reactor and modular that cannot have a corner. you cannot sense it. we can be being irradiated right now and we couldn't have any idea. there -- maybe i'm iranian. you would never know. i think one needs to acknowledge

the fear. we have seen what happens when you drop nuclear bombs on countries, right? we have seen now a large area of japan made uninhabitable. that's not something that you can ignore. i think what's important to do especially from a regulatory perspective is engage the public. listen to the concerns. respond to them. and develop trust. that's what is important. if you don't have the trust and you just please listen to me, i know more than you and just trust me because of that, you will never get anywhere. i think you need that engagement and i think that's the kind of thing that will help. >> let's thank the panel. thank you very much. >> we have coffee out there.

this is our break time. if the poster presenters had the opportunity to mingle with very interesting people. he will talk about his new book 13 soldiers and 13 soldiers at war. he will be talking at the national press club and have live coverage at c-span 2. >> they continue at 7:00 eastern with the white house ceremonies followed by the wreath laying at arlington national cemetery. as well as other collections

from the white house medal of honor ceremonies. group 245s made up health wore workers and medicare patients. over the next hour, the discussion on current state of acs. >> we will move into the next panel and while they are coming up to the stage, i would like to talk about some of the big issues for aco policy going forward. i like to introduce the topic of big issues for aco policy going forward. some of the main topics are what you have already heard. the state of the evidence on accountable care and about some of the key issues and challenges facing accountable care organizations on the ground.

i wanted to highlight a few. one of them is the issue of what we have heard. the benchmarks are calculated and whether the savings are retained overtime and go into a new base. they are transitioning to more personal or more significant financial risk. but it's something that many seem ready to take on. the steps and policies could support increased beneficiary engagement. it's the performance measures

that come up. the performance measures that are less burdensome to report and could be more meaningful for capturing the issues by under use of care and more meaningful patient reported outcomes and the like. we heard about challenges related to data availability since timely comprehensive data is critical to many of the steps to improving care being targeted. the other payment reform going along with the payments that can potentially reinforce their effects. we talked about steps to overcome start up costs through things like bonus payments and other incentives. we highlighted the challenges. it's the opportunity to share experiences and research on

what -- so plenty of opportunities for further discussion and debate and hopefully constructively next steps on the policies affecting the aco programs in the country and particularly the medicare aco programs. very timely issue right now with the upcoming regulations and further payment and regulatory reform that is coming. a great panel to discuss the issues. i would like to introduce them briefly. starting on the far end is the president of heritage medical systems, the president of the provider network that serves over a million patient members and integrated population-based programs through medical groups and independent practice associations in california, new york, and arizona. heritage provider network

manages one of the largest pioneer acos in the united states and that seems to be doing quite well in the pioneer program. joe demoore and premier. the successful reports and health systems. including 19 years and he is successful on several integrated health systems and his expertise includes planning for hospitals and care systems and financial and operational management. business planning and quality enhancement and insurance plan and aco hospital integration. no shortage of stills needed. next, i would like to introduce a long time colleague mark miller and the director of the

medicare payment advisory commitmentee. they are a nonpartisan federal agency that advises the congress on medicare payments. he previously was at the budget office with the health and human resources division. before that was a deputy director of the medicare program. last but not least they share in medicine and public policy, the fellow here at brookings. and change prior to founding health system change. he served as the founding director from the payment review commission and part of the

medicare payment advisory commission. starting out with the opening comments from the distinguished panelists and talking to further discussion of some of the policy issues and solutions on them. >> heritage is at the other end of the spectrum for many people in the audience participating in the aco. for our million patients, 800,000 are delegate and we pay the claims. we probably have 30,000 contracted physicians, primary care and specialty and independent practices and they can actually produce results.

i think it's driven by that experience that was referenced earlier. the doctor has been at this since the 70s and all the ups and downs of different versions of managed air and all the internal things we do for the people. the independent practice that was the first-timer to the aco gets the social worker who will work with the family. how do you survive that? what we are finding given some success and taking the education

road with and the patient or the family member who often accompany them. and they say why am i moved. that will take care. that's a challenge. i think the secret success like the hackensack system, we spend money that we make elsewhere to demonstrate that will work. and if we don't evolve the payment mechanism to something so the big organizations like us

and support systems are from other medical groups. what was done when you give money in advance. let's give it back. we don't have any argment to whether or not you need an air conditioner and a ramp and you don't have to look up the benefit design. the sorry is could you come in this afternoon? if you can't, you don't have anyone to bring you, we will bring you or send someone to see you. we think with all the providers, we are great when they present the care. more importantly; can you find

them before they present and are injured enough to fall in the door so maybe they don't need care or need a different kind or it's not as intense. we think the program is a great learning round. we have proven that with the independent practices. it can be an advocate. >> the team of management who works all over the country in about 150 markets in the last 3 1/2 years, helping them transform into the population on the medicare side. we worked on the commercial side and commercial payers and blue cross across the country and putting them in the district across the country.

we work across the entire continuum. what i will try to do is summarize what people feel about working with that organization. our organizations have done much better than the national average in regard to hitting them and they have done a great job and have got a lot of other who is did well. almost 80% of the organizations we work with hit the minimum. we like to think it's because the exhaust from the success we share with each other. what's working and then the second thing we try to do -- what we find is many organizations try to do too many

things too early. they stage them overtime and there is a staging process that we think works. number one, the pioneer side, people need accurate timely data and we are not there yet. it's like flying a 747 without an accurate instrument panel. if your attribution changes 30% in a quarter, it's really difficult to get an accurate denominator on all of your metrics so we have to fix that. we have to fix that attribution. and on the top line, if we don't have accurate and timely claims, you can't manage on a day in and day out basis. we need to fix that. data is really critical to be successful. going forward. a number of areas need to

change. the minimum savings rate issue. we have so many organizations that hit their minimum savings rate, but what happens next year, it's dialled back to zero again. that doesn't make sense. somehow you should be able to take a credit for the success this year and carry over towards your target for next year. it seems terrible to say well, you did pretty good this year, but you didn't hit the minimum. you will start all over again. that doesn't make sense. we think those things need the change i can give you more and more at the risk adjustment process is not really sound in our opinion. the benchmarking and the metrics need to be setting in their targets rather than saying you have to hit 100% of the metrics in order to get full shared savings. the third area would be where do we think we need to go? we think we need to allow them to continue the one-sided risk

for several reasons. if they don't have accurate places, i don't think it's roept to go to two-sided. that doesn't make sense. the organizations and i think it was great about the types of organizations. it's too early to go to two-sided risks. there organizations that are ready to phase into the risk and they should be given the opportunity to maybe go to track two and phase it in overtime. we have a small number of working patients that want to go to the first we have the full plus part d. we have a way to offer the current piece. the ability to stay involve and

make decisions that fit their market and organization. we are hoping that they will come through. they analyzed the issues and i 78 looking forward to hearing from you. so there is a couple of things. we spent the last year or year and a half talking to aco's case studies surveys. we put together short run comments which i will go through and i will start talking about what the direction is for the future. there two products. i have to mash them into five to seven minutes here.

>> we wrote to the administrator and writing to the hill staff when we do this. that's up on the website and also our june 2014 report talks about the future stuff. based on things we heard from the field that you can reconcile with the taxpayer and beneficiary interest on the medicare side and made a series of the next round of the acos. on the issues of attribution and benchmark or the benchmark which has been mentioned, we made the argument that both need to be very clear and consistent perspective basis. whether it is set up to be retrospective, the attribution changes during the course of the year or the benchmark changes during the course of the year.

>> that changed the benchmark as you go forward. and it should be on a prospective basis. there is a certain stability and just a predictability that we think will allow the acos to manage that are under those kinds of circumstances. the basic issue is attribution and bench moork a prospective basis. a legislative thought on the side, but just to get it out and on the attribution purposes, advance practice nurses and pas should be part of the process. again that requires a change in law. i won't get into law because it's more complicated, but there is a specialty process we talked about changing and we would say those who are engaged in relatively primary care types of

activities. when you are going to your cardiologist and that type of thing. there is more detail, but just to blow by it. that's the deal in our comments. throughout this process, we made the point that there were too many and they were not the best in our judgment that should go and we were concerned about the burden and some of the measurement issues. this ended up being more resource intensive than an 'tis waited. we argued through the process not just in acos, but the servers who are smaller sets of population-based measures. we made that point. there is more detail and complexity and you can look at the letter. we want to encourage the

movement and there is reluctance and concern and we want to move to the risks and there a couple of connected thoughts here. one is we heard a lot of concerns in what was echoed and right here about the notion of being able to engage the beneficiary in order to make them get the leakage issue and engage the beneficiary in their care. >> we made a recommendation that if they are willing to accept two-sided risk, they should be able to forgive the beneficiary. some of the you explain is to explain here's an aco and how it works which is hard to understand. if you go to the primary care physician and from that point. they should know how to manage from that point. the other thing we said is if you accept two-sided risk, there

should be regulatory relief. once it shifts to two-sided, a lot of that should fall away and we gave examples of where we, ourselves, and the rest of the community should start focusing on regulatory relief to roll back. we heard lots of comments want to talk about it. a model and a cap tated model which i think involves more discussion and other ways to engage the beneficiary. the june 2014 report talks about the future and how it fits in the large picture. this gets more complicate and less clear, but the point that we're kind of driving to. it's the notion of a single junified benchmark that said for fee for service and the

government may have sld february awe stromodel and that can come forward. ma plans have a lot of overhead. they process claims and they do that. they have to finance that and make a profit. they might be a model where you have thinner utilization and make that model work relative. >> in a few minutes and giving people the reference. >> i think it's a promising

concept. taking a risk to lower the beneficiary and improve measured quality. good concepts can overcome flawed details. the medicare models have been catalysts for acos becoming a part of providing payment. this is the time to fix as many as possible. my sense is if the aco has been tolerant of these details in the model as long as risk is one-sided. of the prospect of two-sided risk which is not going to get to raised the pressure to resolve the problem. it's not just the organization's capability of taking two-sided risk, it's the confidence in the model and whether they are willing to risque loss on a model they don't believe in. because of the details.

the acl's need that they are for and the ability to reach out and engage them. i had a couple of thoughts and the mark started off in the long run. they had the development of the mod model and they could offer a temporary reduction to go there. enrollment model would allow a met work approach of lower coexperience for network providers and higher for others. it's a way of engaging more

specialists in the aco who may not be part of the risk sharing where they account have a relationship with the hmo. if you go to an enrollment process, you need to find with very low administrative costs. a lot more than medicare advantage. perhaps just involving with the communication from cms and from the aco they are attributed to. would you like to enroll? here are the benefits and that's a way of getting to that model. i would want to run the enrollments alongside the model because of the concern of the number of years it might take and they want to jeopardize the approach in that interim. i think many of the reforeigns and the direction of the patient

engagement that involve incentives are going to need reform of medicare supplemental insurance. we know the medicare rate is overall medicare spending. basically you cannot work with large proportions of beneficiaries having no point of service and financial responsibilities. by the bipartisan center, they recommend that they be limited to providing catastrophic protection and need -- it's the

tight approach to get started with. it's not ideal. we need when we have an essentially voluntary aco program. otherwise they have enormous risks before it. they announced for updating our helpful worst shortcomings to the approach, we are coming up to a critical time. i think rebasing to the most recent experience would undermine the business model for acos. i think the long-term path to better benchmarks involves

higher payment. and perhaps other providers to work in acos and the tricommittee to build really takes this approach when it created apms or alternative payment mechanisms to get into alternative and you can start bringing in community or county-wide experience into your benchmarks with acos and we will have to go in that direction. we talked about the opportunity.

and we should not write off the action for bigger changes and we certainly don't have the greatest expectation and the challenges even where partisan divides are not that pronounced women should have the far reaching changes and medicare fashion payment to fix the sgr that had unanimous anda as seen participating in mechanisms could be brought over. obviously given the fix, and you are waving fashions the

opportunities to get into alternative payment mechanisms. the opportunities exist. that really means that they should be national for the congress if it goes past the lame duck in dealing with the fix. they are not thinking about the payment to really assure that they will be real opportunities for physicians to engage in alternative payment mechanisms. thank you. >> thank you very much. i want to thank the whole panel. i went through a range of each individually challenge iing ande engagement data reinforcing reforms and bonuses for transformation and we heart from the panels from people who were engaged in doing the work now

and you are among them about it's like building the plain out while you are flying it. also what came through is they are anticipating things changing because of market change and the change in the private sector systems and employers and states and things are going to be changing. similarly for medicare as you focused on and many of your remarks. we could talk about the details, but i want to ask you about the

bigger picture. you couched on this and too many marks on this with with the tell us centers and similar kinds of long-term reform recommendations and to years from now, where you like to see the policies collectively get us in terms of support i supporting next rounds of care transformations. back to the bigger picture. there important details that need to be worked out and the big picture, can you all help with the clarity of where they are trying to go?

>> the hopulation base is the key moving in that direction again. that is towards the side as some folks are terribly moving away from the service when you inject fee for service into our system. it screws it up. we will have to go hunting for and pate for and whatever. we tell the doctors to ignore it. most is paid the other way and we will figure it out. population-based payment is key and the enrollment yet that is described here is perfect. these numbers are just old. they are not stupid. if you don't deserve their business because they would choose to stay with you even after that, they make sure it's

every market possible, we have scientists or health plans or anything else. all types of things and think the base line market, we want progress. every market has different characteristics. i spent plenty of times on the coast. we won't say which is left and right, but in new york, in the new york area, when i went there in 2004, it was like rolling back the clock 20 yearings. whether it was benefit design or behavioral practice. the los angeles basin or in the bay area, they are like

communist take over of parts of the new york greater market. everyone now is moving in that direction because i think it was pointed out earlier and the writings's on the wall. having your benchmarks set based on your market other than clinical standards, there scientific things, but the benchmarks for cost are market-based and you need to pay for progress. you have actuaries and at no point united. how do they roll up? you can have 110% loss ratio segments of a plan and if you improve to 105, that contributes to those who were operating to 87. and you are making progress.

let's focus on making progress and the stuff that joe was talking about. if you are too slow, you sweep government reform that will be blunt. >> i will be blunt. >> we call it the end game. a lot of our organizations that we work with, their vision of the end game would be to have contracts with all the major payers and their market. medicare, medicaid, all the -- so if i was the ceo of an integrative system shs, i might have 700,000 people for providing care. i would have probably a global target of expenditures for each group. and then it would be my bonus might be based on quality, patient satisfaction, engagement, health status improvement, so that's kind of what we see as the end game.

there's some evolution that's going to have to occur to e get there. and we're beginning to see the evolution. it's exciting. we are seeing the formation right now in a number of markets of what i would call multiowner health organizations. this is kind of the latest thing that we're working with. individual organizations realized they don't have enough scale population wise or capital wise to be a really strong population health organization. so they are coming together and forming a multiowner population. and i see that as part of the evolution towards this model, so i hope this makes sense. >> i think for the commission, i think we have been -- we have tried to be really clear about specifics in the short run. we're starting to frame up what we think again. these are comments that are smu subject to change as the commission works through them. and again, and i think i probably garbled this, but you could view the world as this.

you have fee for service, and you're probably going to have that for a long time. there are parts of the country where it's a relatively in a utilization sense efficient type of operation. so just keep that in mind. the other end of a continuum, you have ma. and ma pays its own claims, markets and enrolls people and there's a high set of overhead that goes with this. on top of that, they get their u utilization reductions and they get a profit. margin. at the moment, i think the way the commission views acos is standing between that. it's an atricks model and its advantage is that it doesn't have that overhead. claims are paid by cms. enrollment is done through attributi attribution. so maybe they perform well in markets where you don't have high utilization but some that kuld extract a point or two and

because they don't have the overhead can be a competitive model there. i think the commission's view is you don't pick a model. you set a payment system that allows whichever model can perform to emerge in a given market as opposed to saying we should be here or we should be there. some markets, those models will be ma, some markets they will be acos, some may be fee for service. there's a whole quality conversation that needs to happen, but for the moment, i'm going to lay that to the side. now, attribution has this element to it. if you want your patient to stay with you, you have to make them satisfied. hmo they enroll, but they are in there for a year and can switch out. but in attribution, they can wonder around so they have to keep the patient satisfied. that's an important element of what the model requires. now having said all of that, i u

don't think the commission is against an enrollment-based model, but to the extent it takes on all over overhead and enrolling people off the street, you have an ma program, and one question is why would you replicate that somewhere else. i think paul made some important comments of, wait a minute, if you've attributed this beneficiary, you've got them for a few years and they are willing to actively make a decision, that might be a road that could be discuss ed. the last thing i will say, and he may this point, i think it's important important that you need enough and to make these critical -- make them workable mod models and if you had a strictly enrollment model, i'm not sure a lot of acos would get enough people currently. >> i think as far as your comment about flying the plane, i have since, first of all, pretty broad consensus in a

delivery system financing and policymakers that fee for service should shrink. and that whether it's in medicare, whether it's medicare advantage or payments, hopefully we'll become more -- it's getting there is you have to put out a policy. then i think the policy process has been appropriately u attentive to the experience of those that are engaged in these programs. there's a lot of productive u discussion going on back and forth. probably the biggest challenge is the readiness of different organizations to go different steps of the way u towards population growth. i just wanted to mention specifically the comment that joe made about the multiowner care organizations.

that's a direction that i hope we see a lot more of. because my concern is that so much in the way of scarce management resources as well as money is going into mega mergers where i think coming up with multiowner models can actually accomplish as much, if not more, in improving delivery without getting to those resources. and not raising the provider concentration issues. >> after the comments and broad question, i'd like to open this up to questions from the audience. back in the back there. >> claire cruise from the center for health solutions. a couple of the panelists spoke about specialty positions. i was wondering if you could talk about the role currently and where you see that evolving. >> sure, i'd be glad to speak to

that. some physicians like cardiologists tend to be fairly involved in acos. there are a lot of specialists whose care is not that integral with care management that really the acos have no reason to engage them. and so this means you have a lot of the dollars out there really not being part of the aco. i think the problem is the need for network model to get the specialists more engaged. and i mentioned some political needs of providing opportunities for specialists to be involved in acos could happen with the fix that we have seen. >> other comments on this? >> i think one of the things that presents this evolution is big challenges for the organizations that have absorbed a lot of them. so if you're a big multispecialty group or a

hospital system that because of the way the system worked, your incentives were to collect these providers and make sure that you enabled them to do as much as they could. i'll be. polite about that. this is very different. hospitals that are going to move into accepting risk all of a sudden, how long can they afford the subsidization of the losses they take on the big physician purchases they have made. they are very open about that. the model has changed. so your estimates, maybe you sold bonds three years ago. your estimates of how many admissions, how many stints are you going to put in that's fueling your system currently, it changes if you implement everything. it takes time, but it's a big economic issue in terms of how do you change the system, take

that step and still be able to participate. >> two things i'm seeing. in one large organization, they have decided to develop models for three different groups of physicians. one is the primary care and the specialists who are hospital group in the middle. who really do both. so they are looking a at models for that hybrid group of cardiologists to involve them more in managing their primary care load. the second model that we have been working on with another organization is what i would call an episode of care model. so this is an msp that's been successful and they want to further engage specialists and

to look at setting a target with that episode of care and then sharing savings among the mssp and with those specialists. so that's a model to further engage specialists that maybe have not been as engaged in the past. so those are a couple models that we're seeing evolve in markets across the country. >> for the ones involving specialists that are handling r more discreet aspects of care as opposed to the cardiologists who are very much involved in things like coronary artery disease management, diabetes management, things that are part and parcel are there other quality measures that need to be developed. conditions like cancer, rheumatoid arthritis that are not well covered. i want to go back to mark's point. a lot of acos have emphasized

that, look, the measurement and reporting burdens are too high now. how do you reconcile that? >> a lot of places most people are familiar with choosing wisely. we're seeing the adoption of choosing wisely for appropriateness in specialty areas in clinical integrated networks and acos. so that's a way to -- appropriateness is coming into play in those subspecialty areas. i'll turn to mark to comment on that. >> one of the things that was -- that i was thinking about in particular, as we experiment with global case payments and packaging everything up with respect to -- so if it ends up in law or a regulation that's so strongly defined you can't get out of it, some of the science

is moving rapidly. so the same cardiologist that you trusted to manage this big case all of a sudden they are going to be using an entirely different type of approach that doesn't involve the hospital, doesn't involve interventional procedures, involves other kinds of -- your follow-up question? >> that makes sense, but maybe to mark about the measurement issue related to these areas of speci specialty care: orthopedics, so forth that are not well covered in full population performance measu measures. >> this is really nerve racking with all these marks up here. >> so a couple things that commission has said in reacting to these comments. i think the commission's comments in its letter about the notion of letting aco designate

certain specialists a z attribution nodes is directly consistent with what joe was saying for his first model. there are certain specialists that are really more about the continuum of care and coordination of care. there's probably a set that immediately rised to most people's minds where you'd say that's logical. that was driven by some technical problem being created by a second stage specialty assignment, but that's not worth mentioning here. i would say our views are consistent with your first model. to your point, mark, on quality, i think there's real concern and this concerns not just in the aco space but fee for service and elsewhere that if we say, okay, any time we bring a specialist and bring in a provider, we have to develop a specific set of measures on this

point where a lot of people say you have to be able to measure my thing and my thing well. at least at this point, the commission's view is from a payment perspective, the view is more of a population-based small set of quality measures that money can be awarded or not as the case may be. whether your plan or whatever the case may be, and the responsible organization can decide which metrics internally it wants to use to chase its particular model around as opposed to single set of measures for all that type of thing. very great concern on part of the commission that we're kind of overbuilding on the individual measure. so we have something of a different view there. the other thing i would say to this mark, i almost thought you were making this point and if you weren't then you can

disassociate yourself. you have to be very careful about building episodes around specialty care because of what he said. and i think sometimes there's some specialty groups that are waking up to this process and starting to enter and say, okay, you need to build an episode around my care. i u think in some ways, they see that as a way to preserve what they are getting currently and i think we should all pay attention to that comment. because i think those processes could be changing. we should think carefully about how episodes are constructed. >> that was the point, yes. well said. >> i want to say something about the quality for specialty care. i think what mark sketched out was fairly practical, but i don't want to give up on the fact that often specialty specific measures are much stronger as far as outcome measures of quality than the

general measures for a a population. i was influenced by studying the experience with joint replacement. if you look at the very specific quality measures they have for joint replacements, you know, they seem to be much, much stronger than many of the general quality measures that you would for an entire hospital. so i think it's worth thinking about some very strong quality measures that they only apply to a very important frequent procedure and working that into the system at some point. >> we have time for maybe one more, back here. >> i'm from cap g. you guys have all spoken about different changes to the aco program. i was wondering if you could speak about what legislation is needed to make those changes

verse what the innovation center could do to advance the next generation of acos. >> i e know everybody is pointing at mark. >> number one, along with a lot of people, i was going around talking to both sides of everything, i think get. inging the sgr fixed done, it is headed in the right direction. we have to get comfortable that some providers should get more money than others because they are demonstrating participation in an organized system that's suppose. ed to do better things for consumers. i think that i believe it takes legislation to solve the payment changes that are going to go off a cliff if we don't reset how things are paid and the baseline information. so i think you do have to have that. otherwise people who will identify we should change, but

they won't have the league authority from a regulatory standpoint make a change. >> other thoughts on the legislative outlook. >> i don't know about the legislative outlook, but i think a lot of the recommendations that we made in the june letter can be achieved regulatorily, although there are things that clearly require legislation. we tried to point that out as we go. then i would also say that particularly thinking about the future in going forward, there probably is a legislative change that needs to go along with this. it's almost clearer if the congress says these are the changes i want that the secretary will then be much more likely to take those change -- undertake those changes. >> any final comments from the panel? i'd like to thank all of you. for an excellent and wide ranging discussion about policy issues and solutions.

thanks for covering the short-term and the long-term. [ applause ] we are about done. i want to thank all our speakers today and all of you for participating in today's event. we look forward to working with you on these issues in the future. obviously, accountable care and the aco experience is a work in progress with some notable results on quality. some important successes on costs in medicare, in medicaid, in private and employer kinds of plans. but obviously, a lot more work to do. we have talked about some of the research on -- transformation and public policies to support it. we have talked about some of the policy u steps that can help people who are trying to engage in care reform on the ground, both provider organizations and patients and consumers and their families do that more effectively, but there's obviously more to come. just want to also give a quick

thanks to our learning network, which made much of this event possible, both in terms of the technical expertise, the contacts of any of the experts around the country and people who are engaged in if aco activities and helped putting this all together. we have more information available on our aco learning network for those interested. and that's the contact information for it. the workings learning network. for right now, i want to thank you for attending and thank you for your concerns about improving the quality and addressing the costs of health care in the united states. have a good rest of the day. [ applause ]

later today arizona senator and navy veteran john mccain. he will recount the lives of american soldiers who served in conflicts ranging from the revolutionary war to the wars in iraq and afghanistan. he will talk about his new book "13 soldiers: a personal history of americans at war." he will be talking about the book today. we'll have live coverage at 6:30 eastern on c-span 2. the c-span cities tour takes book tv and "american history tv" on the road traveling to u.s. cities. we partnered with charter communications for a visit to madison, wisconsin. >> it it is a glorious service. this service for the country, the call comes to every citizen.

it is an unending struggle to make and keep government representative. >> probably the most important political figure in wisconsin history and one of the most important in the history of the 20th century in the united states. he was a reforming governor. he defined what progressivism is. he was one of the first to use the term progressive to self-identi self-identify. he was a united states senator who was recognized by his peers in the 1950s as one of the. five greatest senators in american history. he was an opponent of world war i, free speech. he was about the people. in the era after the civil war, america changed radically from a nation of small farmers and

small producers and small manufacturers and by the late 1870s, 1880s, 1890s, we had concentrations of wealth, we had growing inequality and the concern of influence of money in government. we spent the latest part of the 18 9d 0s giving speeches all over wisconsin. if you wanted a speaker for your club or group, bob would give a speech. he went to county fairs, he went to every kind of event that you could imagine and built a reputation for himself. by 1900 he was ready to run for governor advocating on behalf of the people. he had two issues. one, the direct primary, the convention. two, stop the interests specifically the railroads. >> watch all of our events pr

madison saturday at noon eastern on c-span 2's book tv and sunday afternoon on c-span 3. a look now at health care policy and accountable care organizations called acos. these are groups made up of doctors, health care workers and hospitals that serve medicare patients. over the next hour, the brookings institution discussion on the kurnlt. state of acos. >> thank you and good morning. i'm going to speak for about 15 minutes and then leave about half the time for questions and answers. partly because that's what mark asked me to do. but partly in recognition, i looked at the other panelists and the people here in the audience and i think very distinguished group and groups like this people like me from the government should do less

speaking and some more listening. so my remarks, quickly i want to give you some big -- very big picture context of how we think of the shared savings program. so starting at 40,000 feet and then coming down fairly quickly to the ground level and talking as mark indicated about we are in development of proposed rule for the future, the next generation of the shared savings program. let's talk to you a little bit about where that might be headed. so first, we're about four years out from the affordable care act and probably more importantly we are one year out from the 50th anniversary of the medicare statute passed in congress, 50 years ago. so where are we? most important measures, which are controlling costs, and improving the quality of care that our beneficiaries receive. on controlling costs, the news

is historically good. we are in the middle, about a four-year period where the cost per capita of providing care to a beneficiary is essentially going to be flat for four years. some of that is data that is already in. some of that is the actuary forecast for next year. unprecedented performance on reducing the growth and cost per care. that bodes well for the program in many ways, one, the trust fund, the life of the hospital insurance trust fund. if you go back to 2009, the forecast was that it was eight years from being exhausted, that it would be exhausted in 2017. this year the trustees are saying we're 16 years from being exhausted, that the life has been extended to 2030. that's good news. also i think when you control health care costs, it allows not just relief for the federal deficit, but also allows for better health care policy. probably the best example is serious discussions now about getting rid of the sustained

growth rate provision in the medicare statute which many feel has outlived its usefulness, but that the discussion to get rid of it is only made possible by the low cost in medicare spending. so that's the cost side. on the quality improvement side, again, historically good news. hospital acquired conditions, many forms of hospital acquired conditions, are dropping. ventilators associated pneumonia, early elective deliveries, i could go on and on. lots and lots of signs of improvement and care in our beneficiaries are receiving. hospital readmissions dropping. one in five medicare beneficiaries, about 19.5%, readmitted to the hospital within 30 days of being admitted. that is now in a precipitous decline now, about 17.5%. so what is causing all this good news? there is a lost factors. some is public policy, predating the aca and out of the affordable care act. some has nothing to do with public policy, changes in professions and hospitals and

delivery system have made on their own, because i think what you see is the beginning of a genuine quality improvement performance revolution in health care, which we had in other industries, but sort of late coming to health care. we see actions by other payers, commercial payers, state, medicaid programs that are incentivizing changes. so we're in very good position, we got challenges ahead, how do we continue this level of performance and improvement? well, first of all, the challenges ahead are significant. one, the actuaries, though predicting that costs will continue to be flat next year, you look further out to the future of predicting a return of inflation of about 5% price growth every year, which is a challenge for us, but more of a challenge is the baby boomers in the next 20 years. we have 50 million give or take medicare beneficiaries today. and in the next 20 years we'll add another 30 million. so 60% growth in the next 20 years.

very substantial challenge. even if we continue to control growth per capita. so that's sort of the landscape that we view the program in. we're in a great position with controlling costs. we have made some significant strides in improving quality. but we face very, very significant challenges. so i think the way we look at the landscape is we need to continue to support delivery system reform and how do we do that? the secretary birdwell, within her first 100 days articulated a vision, providing information to providers so they know how to improve and where they need to improve. improving the incentives, so making sure all of our payments and support improvement. and building capacity within the delivery system for improvement. and i think the aca initiated a lot of that work. if you see on the quality side, on information, we're providing quality measurement in almost every one of our provider groups in medicare, providing transparency with publishing these on our websites, whether nursing home compare, hospital compare, and more importantly, and this is where i wanted to

get to, is we're injecting the notion of value of paying for quality and efficiency into all of our payment systems. and what are those payment systems? very briefly we have the medicare advantage program, we have the fee for service program, and we have got new models of care that mark referenced. in the medicare advantage program, a lot of progress, the affordable care act set us on a course to pay more reasonably, getting significant savings there, at the same time, we're getting higher quality care and medicare advantage, 60% of medicare advantage beneficiaries next year will be in four and five star plans. premiums have been essentially flat since the passage of the affordable care act. good news there. in fee for service, hospital value based purchasing, physician value modifier, even in dialysis payments we're building in the concept of paying for quality, paying for efficiency into all these fee for service models. but as mark said, for are many providers, they believe to truly achieve change and fundamentally change the way they deliver care, they need to move out of fee for service and move into a different model. and that's where acos and other models come in.

i'm not going to go into depth unless we get questions, but the innovation centers testing any number of models around acos, primary care medical homes, lots of variations. i'll focus on acos, but as i say, it is an important part of our strategy on new payment models. so where do we stand on the aco program? early results and i would use very similar slides to what mark did, the early results are very promising. particularly on the quality side. on the quality side it is pretty clear that most of the acos have figured out how to improve care beyond what is provided in the fee for service system. and we see that in beneficiaries. one measure we do is patient satisfaction. patients in acos tend to be almost across the board more satisfied with their care than patients who are not in acos in the fee for service program. there is more quantifiable measures. the pioneers from one year to the next improved collectively

on almost all objective measures of quality. i think 28 out of 33 measures they improved on. in the shared savings program, the shared savings acos outperformed fee for service in 17 out of the 22 measures, where large group practices had reported quality measures. so on the quality story, very good, promising results. on the cost side, a little less -- more of a mixed result so far, but i would caution it is very early in the program, you recall if you went back to january 2012, there essentially was no such thing as an aco. and now we have as mark said -- i usually use the number 360 in the medicare program, but many more in the private sector as well. with 5.6 million beneficiaries participating in them. several pioneers have clearly figured out how to generate cost savings and do that consistently from year to year. a number of shared savings acos as well.

but the story is still mixed and the question isn't can the leading edge figure out how to generate cost savings, but can we get the vast majority of the acos in the long run generating cost savings to go along with the quality improvement. so if the situation is promising, but needs to do better, how do we move forward? again, i go back to the secretary's vision, we need to improve the incentives that the acos receive, improve the information and help build the capacity of the acos. since as i mentioned we're developing a new regulation for the aco program, i can't tell you specifically, but i'll talk about now briefly are some of the areas where the private sector, the acos have come to us, including through the brookings learning network, and have told us areas where they think we can improve. they map perfectly to the incentives, capacity building. on capacity building, we have heard, you know, a lot of small practices that want to get into acos or in acos need help in understanding how to transform themselves. we heard this outside the aco community.

how do we help small practices in clinical transformation? and that's something the federal government is talking a lot about. we even have spoken publicly about and solicited ideas, how could the federal government support small practices in transforming better? but specifically in the aco context, one of the things we heard is, well, since this is fee for service medicine, when we assign a beneficiary to an aco in one year, many of them are not assigned in the second year. and some have referred to that as the churn of beneficiaries. so it is harder for the aco to focus their interventions and resource investments on beneficiary if they're not certain that they're going to have that beneficiary in the long run. i think mark made reference to some of the savings opportunities are in the long run. so we have been talking to the private -- to many of the acos and thinking long and hard how to you get a more stable

population for the acos. the challenge is this is fee for service medicare, meaning the beneficiary is not locked into a network. and then broadly, i think, how do you get a nonchurning is part of a broader category of how do you get more beneficiary engagement. this is true not just in the aco context, but any context where providers are trying to provide care better and in a different way. how do you get the beneficiary engaged in the care so that they're doing self-care, following medication adherence, those sorts of things. on information, we heard consistently that acos need better and more timely information from the medicare program. we have been working hard to do that. we have a ways to go. i would say, though, for the -- in cms's behalf, two years ago

we essentially were sharing claims data with nobody. now we're sending monthly claims fees to over 300 acos every month on behalf of -- with data of over 5 million beneficiaries. this has been an enormous change for how cms saw its role, but i think it has been a successful one, but it has a ways to go. i think working together we can figure out better ways to share information. and then most importantly we heard quite a bit of talk about changing the payment rules for the acos. one of the things we do is we don't pay on the first dollar of shared savings because there say lot of variation year to year in medicare spending, so we create minimum saving ratios, first couple of percentages. many acos balked at that, feeling like they did generate

change it wasn't a statistical anomaly and would like to be paid for that. one of the things that is implicit in all the numbers mark shared on who generated cost savings is what is the formula for what is a cost savings. the shared savings program followed the statute in the affordable care act of using a national benchmark, meaning you start with the costs of your own beneficiaries historically, but trend that forward based on what happened nationally in the medicare fee for service program. couple of things to observe about that. one is it is an interesting time to start the aco program because the fee for service program is essentially been not growing at all. so that's a very difficult benchmark to meet regardless. two, a number of acos have said i'm in a community where costs are growing much faster than the national average. it is not fair to only give me a benchmark that grows by the national average. the only thing i would say is we have been listening very closely to these, but this was the point of contention in the drafting of the affordable care act and it is very delicate regional balances that come out in those discussions.

but we are hearing quite a bit about whether the benchmarking methodology is the one we should stay with. we are proposing that acos that generate savings over a number of years and continue in the program that we would do something call rebasing, which is we're using historical based period, we roll that base period forward. some acos feel like if we keep rebasing them over time, their opportunities to generate savings will be diminished. we're hearing a lot of acos asking us to not rebase or to approach it differently. mark made reference to a lot of acos want to provide care differently in ways that aren't paid for by the medicare fee for service program. and they can do that, but they're not paid on a fee for service basis when they do that. essentially they're investing their own funds. so we have asked -- we have been asked by the aco community for a number of waivers meaning they don't want to have to follow the three-day prior hospitalization rule in medicare, they want more generous access to the home health benefit, and then finally and probably most conceptually tricky as mark said, many of them want to not be paid during the year on a fee for service basis, but would prefer to be paid on a capitated basis. that would free up the dollars for them to do a lot of

innovative things. as i said, it raises some conceptual challenges which is would the acos then be like an ma plan making payments to other providers, would it imply there is a network. these are all ideas we're taking seriously and considering as we propose a new rule. we hope the new rule will be out shortly so the public can comment on it. we will go through the normal public comment period, which is -- this would be a proposed rule, we would solicit comment and adjust the rule as appropriate to public comment and hopefully have a final rule early next year. but, again, this is in conclusion this is a major part of our strategy to continue the improvement on controlling costs in medicare and improving quality. it is part of an array of strategies that range from medicare advantage all the way to our fee for service payment systems. but it is one of the keystones and one we are looking forward to working on with all of you. so with that, i will pause and take any questions. and i'm almost right on time. >> so while sean is getting situated, there is a microphone

you can clip right on there, i'll just start with the first -- we're framing the first question. a very broad overview fitting the aco program into a wide range of payment reforms taking place in the medicare program generally and in cmi in particular. one of the things that you highlighted was basically that -- how important it is to think of acos as not just about a payment model, that there are other changes that are needed too. you talked about a lot of the regulations in medicare's payment systems on things like no requiring a three-day stay at a hospital before going to home health or post acute care facility. uses of home health services, typically limited because of the restriction, because of the fee for service nature of medicare payment.

and you also talked about the need for further steps, for smaller accountable care organizations or smaller provider groups to be able to get off the ground in these kinds of big payment reforms. and i know that more of this is going to come up in that regulation, which is coming out soon. >> soon. >> great. but you have made some other announcements recently from cms, the administration has, that pick up on some of these other issues, for example, just recently advanced payment program for rural acos. i wonder if you could talk more about that, maybe about recent announcement from the office of the inspector general, i believe, about extending program to give acos and some other providers that are participating these new kind of payment

arrangements, a bit of a pass from some of the restrictions on money across providers and the like, sharing resources across providers that, again, are intended to block some challenges in fee for service that may be less of an issue in the coordinated care approaches. maybe you could talk a little bit about how you see acos in the context of some of the other policy changes and where those might be headed as well. >> sure. and thanks for that question. and, again, just part of what i was trying to say in my remarks is acos are important and big and growing part of the program, but they're part of a broader strategy to improve care and reduce costs. on the specific topics you raised, we had as some of you might know created a -- at the start of the shared savings program something called the advanced payment model to recognize there are a lot of providers that say, i get it, i think that's the right direction for us to go in, we can do well by our patients, we can improve the quality of their care, but we see it require an up front investment, but we're just a group of small physicians or rural hospitals, we don't have

the capital to do that initial investment. and so for want of that initial investment we won't be generating savings for years to come, and improve quality. so to help some providers get over that hump, we provided what is called advanced payment, which was the -- the name was chosen carefully. what it meant was this is an advance on future shared savings that you're going to generate. we gave it to 40 some acos and said here some money to help you through the beginning to hire nurses, beef up your i.t. system so you can improve care, but when you generate shared savings you'll pay the money back to the federal government. it has been very popular. some of them did very well in the early rounds of the shared savings program but we also heard that we -- we left some groups on the outside when we designed the original one.

we also heard that some shared savings acos were able to get into the program, but weren't sure they could remain in the program without some help. so we tried to design the new round of advanced payment to capture some who were in who wanted to stay in but needed some help and also rural hospitals, i think we really didn't define it right to get rural hospitals, particular areally critical access hospitals. on the waivers you were referring to, when we created the program initially, i mean, if you can think about the shared savings program, these are often not already integrated health systems coming together these are independent practices and fqhcs coming together for a common purpose, but oftentimes when they do that, they run up against fraud and abuse laws about how much they're allowed to cooperate. the original program included some waivers from fraud and abuse laws, those waivers were due to expire this year. and the office of the inspector general has extended them for a year. i think -- i think once we come out with the new rule and show where the program might be headed, i imagine everybody will go back to the drawing board and decide do these existing waivers still fit the new program. >> it does sound look a longer

term commitment to making sure the fraud and abuse protections are appropriate for the payment systems being used. >> yes. i think you'll see continually as the program evolves, continued re-evaluation of have we tailored them correctly to the way the program is operating and to what providers need and what the government is comfortable. >> in the same spirit of reinforcement of the basic ideas in an accountable care payment arrangement, we're seeing in private sector are a lot of insurers putting in a number of different reforms at the same time, so not just acos with shared savings or two sided risk, but also medical home payments, bundled payments for special services and more advanced care, a number of payment reforms that all can be reinforcing. it will be challenging when medicare is trying out some of the new payment models and

trying to figure out what the effect of each one is. i think what many of the private payers are finding they get more mileage by putting them all in together. is that something that you all struggle with in terms of -- >> we do. but as you know, the innovation center is testing many different models, we have tried to allow participants to participate in multiple models. there is one statutory prohibition, which is provider cannot participate in more than one model that involves shared savings, we try to be cognizant and enforce that. but other models we think could be complementary. it does pose a challenge as you say for the proper evaluation of if you see a positive result, disentangling what contributed to that result. the one promising thing there is with the creation of the innovation center, we have much more robust evaluation of

budgets than we have ever had in the past. so we'll do better, it will still be very much a challenge though to disentangle those effects. >> we'll open this up to comments to those of you in the room. we have microphones. if you put your hand up and wait for a microphone, i'll try to get to as many people as possible. and over here, someone had their hand up first. i'll wait -- just a second. >> thank you. jerry anderson, johns hopkins university. sean, you mentioned the evaluation budget. you have a whole series of evaluations ongoing at cmmi. some programs are working. some are them are not. what are the commonalities of the programs that are actually saving money?

>> first i would say -- i think i'm being rewired. i think it is too early to say. i apologize, but, you know, innovation center's first models went up january 1st, 2012. so, you know, to see measurable results, best case scenario would have been like this time last year. that's if they had immediate substantial impact and even then it would be limited to the pioneer acos and the partnership for patients which is a big quality improvement. but the bundled payment for care initiative is getting off the ground now. some models we have early results. speaking qualitatively from what i've seen and not applying the level of rigor you tried to teach me at johns hopkins, i think what you see is it is providers who are in this mode long before the affordable care act passed, meaning providers who saw the problems with fee for service medicine, but were pursuing the right form of care,

communicating well with other providers, staying close to their beneficiaries, focusing particularly on the high risk beneficiaries, long before all of our payment systems might have caught up to that seemed to be the ones who got going right out of the gate and did well. those of whom are responding to the new incentives i do think there is a learning curve. i think -- that's why when we talk about the shared savings acos, i think you have a mix of those. you have some that are coming in saying, this is great, this is what i always wanted to do and some saying this is great, this is what i've always been doing and now i'll get rewarded for it. so i think early on you're going to see that diffusion of performance, but the hope and expectation is that the big middle will catch up. >> for those early -- those early organizations that were committed early to this kind of approach to care, it is still important, though, to be able to have a sustainable business model to do that.

and do you think the shared savings program is enough to get there, is your sense from many of those that they like to do more in the way of payment reform? >> again, i think there is a huge diversity out there. there is certainly a leading edge of acos that want to move as fast as possible to more financial risk, meaning almost capitation. though they tend to want to get away from shared savings, meaning they want to budget a perspective budget, they want capitated payments based on that budget, and they want to, you know, let the government take a couple of percent off the top as a discount and then on their way. i would say that's a small minority, but very large, sophisticated organizations. i think there is a larger group that are still feeling out what is the business model and what do they need exactly. but many of them clearly want better upside potential with less downside. >> time for another question up here on this side.

>> thank you. my name is lee young. when we are talking about the budget or whether there is care, i have a very strong concern about it based on my research about hospital utilization and based on personal observation. i just wonder if you can address issues about accountability and the record and real patient care. in writing the response is totally absurd. and then you have abuse and unnecessary -- or even mental care. they have a private patient rights advertising they will pay by the hospital, but they are really -- if you don't address this couple issues, the whole thing is meaningless. so could you -- >> i think you're making what is a point that i should have said at the beginning, which is our focus on cost containment needs

to be matched by our focus on quality improvement. i think we have tried to do that, but you're right, anytime you create a new payment -- every payment system has incentives. whether it is positive or negative, whether they move you in the right direction. but when you create payment incentives to increase efficiency, you need to have some confidence that your quality measures are making sure that efficiency doesn't come at the expense of the patient. with that i would say, you know, the results at least so far in a shared savings program are very promising. patients are happier, seem to be getting better care. whether it is the shared savings

program or elsewhere, i think our measures of quality have a long way to go. and i think they have come a long way, but i think there is a long way to go to make sure we're measuring things we care about and capturing -- the other tension i would say is there is attention in the shared savings program between those two would want to measure everything, meaning we don't want any possibility of something adverse is happening to this patient, versus the acos saying don't drown us in reporting and measurement, allow us to focus on things that are really mattering, that are a handful of really salient measures. and i think that tension hasn't been fully resolved. >> right. one that is part of the reason why you're doing so much work to try to expand out the scope of measurement while still reducing the burden on providers. point out there are a lot of aspects of patient safety where it is very much aligned with the reforms and accountable care.

so preventing rehospitalizations, avoiding costly medical errors that lead to complications, all those are steps that i think accountable care organizations, like the hospitals that you mentioned, now that the payments for admissions are being reduced, those organizations have stronger incentives to address. are there any particular areas where you're worried about the other direction, that the higher quality care may actually be more expensive, maybe for some special -- some special conditions where there are expensive treatments needed, any particular areas stand out there? i know you're generally trying to pay attention to these issues. >> yeah. what i would say about that is we have had some technology firms, some medical device firms come and say, you know, this new payment is wonderful, but you're going to squelch innovation. and what we have said is, you now, we don't want to squelch innovation. there is a type of innovation as

you said that reduces costs. even the ones that may increase costs but that are life saving or life enhancing, so we're trying to find ways to measure that. we have been working closely with those industries to try to see if our payment system should adapt and allow -- they asked for a pass through meaning. we come up with something new, don't include it in the reconciliation whatsoever. we're not willing to do that. but we're continuing to focus on that to make sure as you said we're not that particular type of innovation isn't being -- >> i would like you all to join me in thanking sean cavanaugh for joining us here this morning. sean, thank you very much. later today john mccain. he will recount the lives of american soldiers who served in conflicts ranging from the revolutionary war to the wars in iraq and afghanistan. he'll be talking about the book

today at the national press club. we'll have live coverage at 6:30 eastern on c-span 2. c-span veterans day coverage continues tonight at 7:00 eastern with selections from this year's white house medal of honor ceremonies followed by the traditional wreath laying ceremony at arlington national cemetery. then at 9:00, the u.s. gala featuring martin dempsey and discussions on veterans mental health issues as well as other selections from the medal of honor ceremonies. the 2015 c-span student cam video competition is underway. open to all students to create a five to seven-minute documentary on the theme "the three branches and you", showing how a law in the federal government has affected you or your community.

there's 200 cash prizes for students and teachers totaling $100,000. for a list of rules and thousand get started, go it to student.com.org. the brookings institution has a look at health care issues facing accountable care organizations, or acos, groups made up of doctors and hospitals that serve medicare patients. this is about 45 minutes. >> i'd like to welcome all of you back to brookings on the state of accountable care. we have had a chance to hear this morning already from shawn cavanaugh, cms perspective on where accountable care is headed and a panel of expert researchers on the evidence so far about accountable care. we're now moving into our next panel, which is more of an on the ground look and set of p

perspectives on big issues for acos going forward. what we want to do now is turn to some of the major challenges on the ground for existing and new acos as they implement changes in. practice and as they move forward on engaging and activating patients as they take steps towards a culture change around improving care and focus on values. you have heard in earlier remarks this morning. in those panels, there was a big emphasis on patient experience and patient engagement about some of the challenges to that based on both the way that americans historically gotten their health care and challenges related to the fee for service payment system. on the other hand, patients have been skeptical about being engaged in patient reforms that are in the name of improving quality, but too often end up

seeming more focused on reducing costs and reducing access. so this is the set of issues around challenges for acos success are definitely focused on some of the challenges around effectively working with patients in new ways and these new kinds of care models. just briefly, i have highlighted engaging beneficiaries as a key challenge facing accountable care today. payment formulas based on quality and cost is different than paying based on volume and intensity, as you heard earlier. the methods are evolving and may not be as aligned as they could be with better care for patients at a lower cost. we have talked about baring financial risk on one hand the advantages of moving from shared savings to more of that first dollar ability to redirect

resources to improve care and lower costs, but also some of the concerns about skimping our access to care that come along with those kinds of larger shifts. managing start-up cost with other reinforcing payment reforms like medical home changes and other kinds of value-based payment reforms and finally identifying best practices for clinical transformation. this is hard work, as you've heard and the best step forward for a particular organization depends very much on its market circumstances, its own characteristics and the best opportunities for improvements with their patient population. all this makes ago an aco a

challenging task to undertake and we've got a panel to discuss some of these key issues relsued to accountable care organization related to success going forward. i'll sbree deuce them now and we'll hear from them. jennifer sweeney, the vice president at the national partnership for women and family where she works with foundations, federal government leaders, health care providers, community-based organizations, consumers and others to develop and implement strategies for improving the quality, safety, efficiency and patient and family centeredness of the health care system. jennifer has extensive experience with multistakeholder engagement and processes intended to achieve these goals and a deep knowledge of delivery system models and quality improvement strategies aimed at more parent centered high quality health care. next is kelly taylor, the clinical director of quality improvement for mercy clinics in des moines. she received her bsn and msn

from the university of iowa she's national certified in case% with over 5 years of case management and disease management experience in des moines. she's getting some firsthand experience with some of these challenges and opportunities in not only case management and disease management but engaging patients more effectively in their care. finally mori macker, the president of hackensack alliance. morey has been a member of forest health care associates since its inception in 1997 and he's worked there on implementing a comprehensive multidisciplinary approach to help patients become partners that their own care and wellness and is engaged on the ground with trying to implement these reforms. so i'm going ask our panelists to make some opening or framing comments then we'll have a

back-and-forth discussion. jennifer, i'd like to start with you, please. >> sure, thanks for having me. i enjoyed this morning's presentations. so i work for the national partnership for women and families. we're here in washington. we are a consumer organization and we've been around for more than 40 years working on health care issues including system delivery reform. as a consumer organization we have historically been supportive of new delivery models that have the potential to lower costs, to improve outcomes and to improve patient experience so from the beginning we look at acos as a potential benefit to consumers and patients. i think like the providier community, we've also had concerns about acos and you touched on some of, that mark, in your remarks. i think the two biggest concerns we've had is that this would devolve into just a financial mechanism instead of acos taking

the opportunity to really transform care clinically. the second concern we've had is on the issue of patient engagement. sometimes when people talk about that it sounds like what we're looking for is patients to be better patients versus looking at people to partner with patients at multiple levels and i'll go into that in a minute so as we look across today's landscape, we see variability as well in terms of those two areas. we think some acos are looking at this as an opportunity to o transcare clinically. some are looking at this as an opportunity to partner with patients versus getting them to be better patients but my sense

is that a lot of acos have shelved those two issues and i understand to some degree there's a lot of challenges in starting up a new business model, the financing, measurement, attribution but as i look forward into the future in my mind representing consumers and patients this model won't realize its potential without the focus on the clinical transformation and patient engagement. so i'll take another couple minutes to talk about the patient engagement piece. i think there's four levels that we see patient engagement. first is at the dprekt care level and things like shared decision making. second is the governance level and it's interesting when i talk about that with acos about including beneficiaries on the governing bodies of acos as a way to help the aco understand what it is patients need and want from an aco i'm seeing a lot of confusion about that and

lack of interest which is concerning to me. the second piece is partnering with beneficiaries and patients at the design level. so we know that some acos are doing a good job of not just surveying patients about their experiences in the aco but they're forming patient to family advisory councils and working with council members to co-design care that meets their needs the other level i would say is also the community level. i think in my experience acos but health care providers in general don't partner with community-based organizations like meals on wheels, like the area agency on aging. those are critical to doing transitions while among many other things. the last thing i want to speak o to is this concept of whether or not patients will stay in an aco and how we help them understand that they're in an aco. and one of the things i'm hearing recently is this concept of marketing to patients about

an aco and i really think that's a misguided approach. i think we need to take a building awareness and education approach instead. this isn't a sales pitch. patients don't immediate to be sold on acos if they're getting that patient-centered care they need and want and if they're being partnered with at all four of those levels. so i'll stop there. >> my name is kelly taylor and i'm the director of quality and care management for the mercy aco mercy clinics has traditionally for the last 12 years worked on care transformation focused at the primary care level. in february of 2012 we became an aco and on 1/1/15 we'll have over 200,000 patient and about 1,800 providers. so we've had rapid growth and

that's one of the big challenges, i think, to sustaining this. we have been successful as an aco, surprisingly so. i think one of the things the data puts you on is this roller coaster because in our interim report we did not share enough -- save enough monies for medicare. in our final we did, by a lot. and so with that it kind of was the cumulation of a really good year for us, both in this commercial setting, the governmental setting, and then also in our -- with our own employers, our own employees. so we have a big initiative in working directly with employers now going on as part of this work. i think part of the reason, kind of taking off on your comments, doctor, about that this is here and it's near stay, i think one of the reasons we were successful is we've kind of been saying that my leader, dr. david

swisskowski who may of you probably know has been saying that for ten years. we've been planning and working that the for ten years. so for those of you who are in 100% fee for service world like we are in iowa, you don't have to wait. you can do it now and you can make it work in a fee for service world as well ten years ago we did some fairly inexpensive things in terms of implementing disease registries which are a heck of a lot less expensive than emrs and you can get an immediate return on investment with them. and we embedded health coaches in our primary care clinics. and in a fee for service world, that more than paid for itself. the way -- i didn't have to have a growth strategy for health coaches because once the providers realized that this was good care, they could be successful and pay for performance and they made a little money on that in a fee

for service world. and now this same group of wonderful nurses are leading us into the value world. so the same things that they've been doing all the time, working with patients, focusing on quality, working with them on the issues of medication adherence, of self-management support, finding out from them what's important to them. what do they want out of their health care? and helping the rest of the care team then implement those importances and desires has really been, i think, what has made us -- has made us successful and i think is going to take us a long way into the future as well. >> thanks, kelly. >> thanks for inviting me today. a little bit of background. i've been a practicing internist for about 30 years