on is leading is it seems to me given these differential regulatory possibilities that we may wind up with a group of folks having to go through the entire diagnostic code manual to decide which one requires a personal visit and which one does not and that will entail all kinds of special interests getting in on this. howprevent this from becoming 10,000 pages of regulations that nobody understands? >> it sounds like you've seen those regulations on some other issues i'm guessing. >> i'm thinking of a person -- famous person from m.i.t. >> so i think that you're asking a very, very good question which is -- and this is partly about the approach to regulation. how do you strike a balance that's not such a kind of jerry rigged balance that it's

impossible to actually apply. and it makes things frustrating for literally everyone. and that can happen as part of regulation. i think -- you know there are organizations that their expertise is in trying to cut through very complicated issues and come up with very clear guidelines. examples would be compensation programs that get set up or, you know, military, former military members who have been exposed to certain things, what are their criteria? well, you could go through -- you come up with the most complicated flowchart in the world or basic criteria that are fair and reasonable and able to be applied. the institute of medicine of which i'm a member, does this a lot. they take very thorny questions and they say we need to come up with a regime for doing this that is implementable and reasonable that will bring people together across an arab shoe. then they'll say this is an approach that would be in the public interest. and nothing's perfect but this

is the best we think we can do. so you have to charge -- in my opinion, it's not -- i used to think a lot at the state about stakeholder groups versus expert groups. and, you know, oh, we're going to get a stakeholder group together and it will have 25 people on it and each one will go back and check with their own group. that would be -- people would say to me when i would hear about this that, like, your next career is not as professional poker player josh. because i would make a face just like you. i would like b likebe, like, oh no how are we going to get to a process if everyone feels beholden to their individual group? on the other hand, if you set up an expert group which can have public input and participation in but people aren't representing their group an they're given a very clear charge and you've got a great person leading it, you can really get reasonable things and people just have to -- you know, you're striking a balance. you have to set that up. so i think it can be done if you think of organizations that can do it and then you give them the

challenge. >> you know, another possibility is that maybe we don't need a multitude of complex rule. maybe there's actually a simple rule and the simple rule is the doctor has to exercise professional judgment and so for example in ron heinz's case, if the animal actually -- let's say he examines an animal. he is legally authorized to euthanize the animal, he can amputate a limb, perform surgery, provide powerful drugs based on his exercise of professional judgment. that's what being a texas licensed veterinarian means. and there are plenty of intook places in which we would talk to somebody via the internet and he would say "you know what? you're presenting questions and i can't actually give you good advice because it seems to me the nature of your problem isn't amenable to a telemedicine solution. so you have to go see a vet." so rather than think well we have to enumerate every conceivable permutation of the doctor/patient relationship in order to regulate it, what we should say is "when you have past the threshold requirement of actually bag doctor and we

have invested in you the authority to exercise your professional judgment, then engaging in responsible telemedicine is just an extension of that authority." and that seems to make sense. i said this to the court repeatedly that if dr. heinz can do all of these things to an animal in person why do you think his capacity to exercise judgment utterly disappears merely because he's having a conversation over the internet? it doesn't make any sense. there's no rational conception of a doctor and patient in which that makes sense. >> the issue, though, is that where the regulation is going to happen. so let's say the animals were in another state. he's taking -- he's charging for the advice he's giving. but the other state has basically no ability inside that state to challenge any problems if they were serious problems. so there's at least a -- i think a clear risk to consumer

protection if you were to just say "you're a doctor in maryland. it's up to you, your judgment, whatever advice you want to give, medical advice prescriptions, anything on any topic." because i can take care of big people even though my specialty is in pediatrics and it's all back on the maryland medical board where they can't very easily go out to somewhere else to evaluate the care or see what's going on. that strikes me as a framework that could be quite risky. >> although you might have -- you know, there's this general concept of law that if you enter someone's jurisdiction and do something that a tortus you can do things that can be held responsible in that jury diction. so if we had reasonable jurisdictional practice, and you can say if i'm a doctor in texas talking to southbound in maryland, just by operation of general principles of jurisdiction, if i do something that results in harm, i've

subjected myself to the jurisdiction of that bord and i can be disciplined or do whatever. you're the expert in that area but i mean thing that struck me about the licensing case in the general approach to telemedicine is that we trust physicians to exercise reasonable judgment in the in-person context and i don't know why we're terrified of them being able to exercise similar reasonable judgment in the telemedicine context. they're still grown adult they have medical licenses but i understand the complexities it prevents. >> i don't want to go too far but there's two things you have to tease apart. if it were all within the same state i would be very much -- much, much, much closer to your position. it's when you split the jurisdiction and make it harder for people who could be harmed for -- i think you wind up with a potential for a policy failure. >> i think another question in the middle back.

>> wes coopersmith from generation opportunity. a lot of the telemedicine regulation we're talking about could be construed over interstate commerce. one physician for one state talking to a patient for another state. should states be allowed legally to regulate that type of commerce. >> >> let me turn it over the the constitutional lawyer. >> the question is whether or not when a state is attempting to regulate the movement of medical advice or some kind of occupational advice across state lines, what does the dormant commerce doctrine which says states can't create unreasonable barriers to interstate commerce. was what what does that have to say? it's not popular among the supreme court but it hasn't been very clearly litigated. there's actually some -- there

is some federal appellate law that says what the dormant commerce clause is really worried about is the movement of goods. and if it's just cash or advice that may not actually be something moving in interstate commerce, it's probably not tenable and there will probably be disagreements about it. as i understand it, the telemedicine problem hasn't been considered primarily as an interstate commerce problem. although it strikes me that kind of thing will ultimately be litigated. i think the right answer in constitutional law is maybe so i don't know. i can't give you a definitive answer. >> i saw the guy in the fourth row there. the podium is blocking you. we'll get to you next. >> victor rotzee institute for justice. this is principally aimed at dr.

sharfstein but weigh in as you see fit. is it remotely realistic to expect any sort of regulation of telemedicine to be enforceable? i mean i see a host of problems in -- if we set up this vast regulatory framework assuming that there will every be a consensus on it in which you would have to record, for instance, skype conversations with your doctor. or i see, like, nightmare scenarios where state medical boards are partnering with the nsa to get data and be able to regulate that way. so i just wonder how exactly could any regulatory framework around telemedicine really ever be enforced? >> well, i could see your nightmare scenario and raise you another nightmare scenario but i won't do that. you can have a lot of

discussions where you're trading nightmare scenarios. i think rene laid out a framework and i would be interested in his view about whether it could work if it were picked up. so you have compacts where people can see patients across state s states. if that were to be facilitated people could see patients across states and the enforcement would come that if somebody stepped across the line did something that was wrong, there would be a complaint, a medical board would then be able to take action. and i don't think that there's any necessity that there be some kind of crazy amount of surveillance or anything else. most things are done by -- doctors have an obligation to take medical records just like they do in the -- in-person requirement. in-person medical practice. if you were a doctor in another state and i felt there was a problem i would explain it and

people would look at your records like they do at any medical board case and have to make decision. it might be hard to make but then you would have a framework because you would be licensed in your own state, and in many state and the process could play itself out. >> the thing with compacts you're only as strong as how many states are actually part of the -- so licenseure compact, it's a great idea. you're licensed in one compact state you're deemed to be licensed in the other compact states. some exceptions apply. the problem there is is if you look at the map of who is part of the compact, a lot of your biggest states are not. so you're left with a situation where a lot of your least-populous states are members of the compact and your biggest states are not. >> right. >> and if you look at the folks who have -- the states that have decided to be part of the physician licensure compact with states like -- i think it's west virginia, one of the dakotas,

idaho, california's not going to do it any time soon. texas isn't going to do it any time soon for all kinds of reasons. so compacts solve part of the problem but they're only as good as how many states are part of the compact. >> well, i think if this were an easy problem to solve simon wouldn't spend his time on it. there's the question of how easy it is to get it done and then there's the question of how to get it work once we get it done. it won't be easy to get rid of state medical boards either. but while you're in the system, the fact that there are some efforts moving forward, it could be that that is the most likely even they're all somewhat less likely to overcome the professional problems that you have. >> and i don't get a sense that there's heavy support for a national licenseure system on the hill. in fact, it'ses a non-starter for a lot of folks. >> i think i've been missing a question over there on the left.

>> my name is nicole roz, a reporter. i cannot stand up, i'm kind of swimming in equipment over here. i have two questions. the first i'll direct to dr. sharfstein and whoever else would like to chime in. could you talk about tim pact on health care jobs that telemedicine will ultimately have. you can talk about how on one hand there's a shortage of position, on the other hand telemedicine is clearly moving towards remote monitoring. who will be monitoring all that data? and it's not necessarily a full-time position. so i'll start with that question. >> that's a great question but i don't think my professional training gives me a great answer to it because i'm not an economist. i do think they're obviously going to be implications. i guess what i would say is that you can look at the country and see a mismatch between need and

resources for medical services and the goal would be a wwith a good telemedicine program to address that mismatch to people who need it and in the end get better health. that would probably allow more flexibility for where people could live but in terms of what that would do the work force in different places i don't know the answer to that. >> i think it's fair to say it would be disruptive and maybe your view of it depends on what you think about disruptions and many of us, including me, love to have the economy disrupted and have consumers benefit from that but i understand there are other people are maybe more about disruptions to people's work lives. you had a second question? >> second question, this will be towards the first speaker but if anyone else wants to chime in that would be fine. the federation of state medical boards changed their definition of telemedicine in april to include video teleconferencing

but not audio only phone conversation. i'm wondering how much weight does that hold if that matters and the degree to which people can -- the degree on a definition and how that might impact patient care. >> the definition of -- you're absolutely right. and the model policy they redefined telemedicine and left audio only out. a lot of states have their own definitions of telemedicine and a lot of them don't include audio only. so i think the fsmb definition was not a surprise at all. the definition is only important in that the fsmb model policy addresses telemedicine so anything that falls outside of that, the rest of the model policy does not apply. i think if you talked to a lot of folks a lot of folks will tell you that patients -- a lot of patients prefer phone. it's more convenient, it's much more accessible to them.

you don't need broadband and a lot of employers will tell you that when they give the choice of their employees as to whether or not they want to receive services by phone or by audio video, a lot of them choose phone because of the convenience factor. having said all that i think even the -- some of my clients who are in the business will tell you you can't do everything by phone. there's certain things physicians will not do by phone will refer you back to your primary care physician and so the phone cant solve everything but i think the people i speak to, the people i represent, the employers i talk to would like a more expanded definition of telemedicine to include audio only. having said "audio only," that doesn't mean the physician doesn't have access to the patient's medical record questionnaires. so it's not just a cold phone call without any other information. >> thank you, we have time for one more question.

>> thank you jeff pearlman just a lawyer off the street. doctor, you indicated that you supported mr. rowe's positions on consumer affairs i guess, so long as it was limited to one state. is i think that's what i understood you to say. so is it true if i live on western avenue the borderline between maryland and d.c., anything that happens anywhere in the district if i want to call if i'm the veterinarian and i get a call from the amputee that it's okay for me to answer yet if my friend of 40 years who's also an amputee lives across the street in maryland and i cross the street to answer his question about his dog that the suggestion by mr. rose that that could result in a -- that could be resolved by a

cause of action in tort law, that wouldn't be adequate? that's not an adequate -- >> i understand the question. i appreciate it. i think first of all i think there is a different issue within the state versus between the states and i think that to the extent that what jeff is saying is that there is a first amendment issue in the doctor/patient relationship and it needs to be balanced in different ways. i think we're pretty close on that. as you get across the -- across jurisdictions then it has a lot to do with enforcement. of course, the case you're talking about, there's probably -- we're also talking about charge i would imagine. you're not just walking across the street because you're doing it. somebody is actually getting paid for something. and i don't think in always all the balancing it's that much of an imposition for someone to get licensed according to that --

get judged according to our system that we've had for regulating professionals. i see value in that. and just -- i don't think the fact that there are always going to be cases that are across the street wherever you talk about any law. is it fair you can do one thing in one state and another thing you can't do across the street? well, that's not the way the law works. if you believe there's value to allowing local regulation of medical practice, which i do believe then you have to live with the borders that are reflected in that. i think it was just a crazy insurmountable hurdle i would have a problem with that. it isn't. if you're literal living on the line you should be licensed in both places. >> i think i should point out that last i heard, fsnb numbers only 6% of physicians are licensed in three or more states. so while we're talking about this new innovative movement

that seems under way most practice is still local. and the question then becomes as we become more -- as -- we're an increasingly mobile society. are the numbers so low because the administrative burdens would have to apply for a license, it's costly or is it because it reflects the reality of medicine on the ground, that it's mostly local? >> we're going to adjourn for lunch on the second floor. maybe the panelist cans join us so if you have other questions feel free to join us up there, see if you can accost them. let me thank the panelists and give them a round of applause. that was an excellent panel, i enjoyed it very much. hope you did, too. when congress is in session c-span 3 brings you more of the best access to congress with lye coverage of hearings news conferences, and key public affairs events. and every weekend, it's american history tv traveling to historic sites, discussions with authors

and historians and eyewitness accounts of events that define the nation. c-span 3, coverage of congress and american history tv. >> the 21-year-old accused of killing nine people at a church in charleston, south carolina, on thursday was denied bail. the magistrate judge seat million dollar bond for the weapons charge against dylann roof but does not have the authority to set bond for murder charges. that will be left up to a circuit judge at a later date. reuters tweeted comments from south carolina governor nikki haley who says as a result of this shooting the confederate flag over the state capital must be addressed. a few years ago, c-span toured the church where the shootings took place. >> denmark vescey was a quintessential charleston man

because he represented an enslaved population he spoke the aspirations of people in this city, this this state throughout the 19th century. he was a member of what was then known as the african church in charleston. and the african church in charleston was an independent african-american denomination in the city affiliated with the ame church, or the african methodist episcopal church that had been founded in philadelphia in 1816. this is a significant development and a significant point in history because the

black charlestonians who created with this church and affiliated with the ame church in philadelphia were affiliating with an abolitionist church and they were attempting to run their own affairs in the midst of a slave holding society. as you might imagine that african church its leaders and vesey was one of its leaders, the church was temporarily closed down on one more than occasion. and we think that it was probably the persecution of this church as well as denmark vesey's personal dissatisfaction with his inability is to enjoy

his fruits of freedom as a free black and his inability to obtain freedom for his children, he was not able to purchase their freedom it may have been those factors that led him to begin to organize a conspiracy of slaves in 1822. and let me tell you about the plan. the plan was to organize slaves in the city of charleston and for them to arm themselves set fire strategically to a number of locations around this city and then to call in slaves from the surrounding area to occupy the city. as it turned out, word would leak out, there were some informants slaves themselves who informed on the conspiracy. and denmark and others were arrested they would be tried and, of course, a trial on these kinds of accusations virtually always lead to conviction and execution execution.

so indeed in the summer of 182 22, denmark vesey along with 32 others were executed by hanging on the outskirts of the city and 37 other people convicted of participating in the conspiracy in one way or other. today we're standing right in front of emmanuel ame church downtown charleston oncale calhoun street. this is important because of the connection to denmark vesey. the original builder was denmark vesey's son and the members of the original african church that remained in charleston really comprised the nucleus for this congregation and for this place of worship when the african church or the ame church was in effect reorganized and reestablished in the city of

charleston in 1865. >> nine people were shot and killed at emmanuel ame church wednesday night. the 21-year-old suspect has been charged and bail on one of the charges against him for weapons was set at one million dollars. any bond on the nine murder charges would have to be set by a circuit court judge at a later date. coming up live today, coverage of president obama's remarks in california. he's speaking to the u.s. conference of mayors in san francisco talking about the economic health of u.s. cities. we'll take you there live 5:15 p.m. eastern on our companion network c-span. >> this weekend the c-span cities tour is partners with comcast. to learn about the history and literary life of key west, florida. earn esrnest hemingway wrote several of his novels in this home in key west. >> they found this house for sale and bought it for $8,000 in

1931 and pauline converted this hay loft into his first formal writing studio. here he fell in love with fishing. he fell in love with the clarity of his writing, how fast he was producing the work. in fact, he knocked out the first rough draft of a farewell to arms in just two weeks when arriving in key west. he once had a line that said if you want to write, start with one true sentence. >> each book should be a new beginning where he tries again for something that is beyond. he should also try for something that has never been done or that others have tried and failed. >> key west is also where president obama harry truman sought refuge from washington. >> president truman regarded the big white house as the great white jail. he felt he was constantly under everyone's eye so by coming to key west he could come with his closest staff, let dun his hair,

sometimes some of the staff would let their beards grow for a couple days. they certainly at timesed off colored stories and they could have a glass of bourbon and visit back and forth without any scrutiny from the press. a sportswear company said a case of hawaiian church with the thought if the president is wearing our shirt we'll set a lot of shirts and so president truman wore those free shirts at first year and then organized what they called the loud shirt contest and that was the official uniform of key west. >> watch all of our events from key west saturday at 5:00 p.m. eastern on c-span 2's book tv and sunday afternoon at 2:00 on american history tv on c-span 3 the bipartisan policy center recommended ways to improve

health and health care in america focusing on prevention. the recommendations came from the group's prevention task force which discussed the findings and talked about how prevention can be integrated into health care. their discussion is about an hour and a half. welcome and thank you for being here. i'm liesel loy i direct our prevention initiative. we are delighted to release the recommendations of the prevention task force, a group of experts from multiple sectors, public health, health care, government academia who over the past year brought their collective wisdom to bear on one

system. how can this help us achieve our shared goals of better health and lowered health care cost. we would like to thank all the task force member ss who's here and our colleague senator bill frist who's not here who served as senior advisors to the project and also the centers for medicare and medicaid services who provided by input along the way and who you'll hear from in a moment. finally last but not least, we would like to thank the john and laura arnold foundation for their generous support of this work. . prevention is a powerful and underused tool in our health system with great potential to reduce spending on treatments and medications for sick people. yet currently our system undervalues prevention.

particularly on the costs and cost effectiveness of those interventions. i should make clear that when we say prevention we mean not just clinical prevention like mammograms and immunizations but also community-based intervention having to do do with diet and activity weight management programs for example, for pre-diabetics. the task force concluded that there are two distinct but mutually reinforcing components of a strategy to better integrate prevention into the nation's approach to health care. first, we need to continue to build the evidence base around what works to improve health. and to evaluate the cost of those interventions to help policymakers understand what to invest in. this will give us what we need to act. a moment and a perfect data set

that we know doesn't exist. we also need a concurrent strategy designed to complement the first component and unfold alongside it starting now. the second component of the strategy is to integrate prevention into the existing delivery system. we have a moment and opportunity right now to integrate prevention into the changing delivery system. as our system shifts away from a largely fee-for-service model and toward more value based integrated models of care focused on quality prevention emerges not just as something nice to have but to help dlif better health at lower cast. when we think about operationalizing these ideas one key feature emerged as critical during the course of the task force's deliberations.

. in its 11 recommendations for how to begin implementing these changes, the task force focused on a number of areas to better link clinic and community. and i'm just going to touch on two. the task force recommend cms fund a accountable community demonstration to test drive an example of that more integrated approach to delivering health and how it could be funded sustainably over the long term. the task force also recommended that quality measures by adopted as part of the core set of measures as a way to activate the resources of multiple sectors together in the service of better health.

but we have real experts here on the panel. so let me introduce alice rivlin and we will proceed. it is a pleasure to introduce alice who has advised and led and chaired and co-chaired a number of projects over the past five years including this task force of bpc project on debt reduction and our 2013 health care cost containment project along with senators domenici frist, and daschle. she's currently director of health policy center at brookings and was omb director from 1994 to 1996 and founder of the congressional budget office. >> thank you liesel. i'm delighted to be back at the bipartisan policy center. i'm a recidivist. i get back here fairly often and the reason i get back here is because this is where serious substantive discussion happens across party line ss oso that we

can make progress on doing something not just shouting at each other from democratic and republican corners. so i love this place whatever the subject is. and today's subject is preventing disease. now, everybody thinks that's a good thing. but we're not doing it. and we're not doing it nearly as much as we could. let's be clear first why preventing disease is such a good thing. why did we all come to listen to this program. i think it's mainly because health is a good thing. that sounds obvious. but health is something people value above all else. i think our founding fathers should probably have talked

about the pursuit of health rather than the pursuit of happiness. happiness is elusive, comes and goes and isn't very measurable. but good health is something that makes everybody's life better. should we value prevention of disease because it saves money? that's a good thing. but it's a by-product. donald shack is going to talk about heart disease prevention in a minute. and it's probably true if you can prevent somebody having a heart attack that would take expenseive surgery you would save money: money:. but you don't want to be the patient in the operating room with all the doctors trying to fix your heart.

diabetes is another example. if we could prevent people going blind or losing limbs because of advanced diabetes, it would probably save money. but that's not the reason to do it. you want to do it because you want to be healthy and not have extreme symptoms or any symptoms of diabetes. there is, of course, a danger in overestimating the economic value. those of us who don't die of disease early live longer and that costs something. but that so we have to be careful november to have the illusion that if we were really good at prevention all our health costs would go away. we're all going to die of something eventually. but we aren't really good at prevention. so why aren't we doing better on

preventing disease? i think there are three reasons. first it's really hard because it takes behavioral change changes in diet and exercise and smoking and substance abuse is and we aren't very good ourselves and the scientific community doesn't know about how to motivate people, to change their behavior. we're learning a lot about that and i think we do know that social norms matter. that group dynamics matters a lot and we're learning things that work but we need to redouble efforts on that. second, society doesn't make healthy choices easy. you skrnt a good diet if you don't live a neighborhood where you can easily buy fresh food. you don't exercise if!ít you're afraid that you'll get shot if

you walk out your front door. your children3 don't walk to school if it's a dangerous thing to do. so there is much our neighborhoods andr8rqnpxéour housing and the segregation ofie communities that would help a lot. but the subject mainly on our minds today is the third thing that our health care system isn't focused on health. health care providers are not primarily trained or motivated to keep people healthy and out of a hospital and out of the doctor's office. they are trained to cure disease. so what is it going to take to change that? it's going take a culture change in the health provider community. it's going to take a work force change in the health provider

community, too, you actually don't want highly trained surgeons advising -- sending a lot of time advising patients on how to get more exercise or what they ought to eat. you want somebody else who knows more about it and was trained to do that to do it. it's going to take changes in our reward system and as liesel pointed out this is the great moment because we are for various reasons in the middle of a payment reform revolution in health care. it is moving toward rewarding health care providers for keeping people healthy, but it's not moving very fast and it's not including the community members, workers and

professionals that could help accomplish that. and it's going to take gradually building our knowledge base so we know more about what health providers and communities and others can do that actually works to improve health. that's a large order. but my next step is a good one. it's to sbreeintroduce one of my favorite people. dr. darshack sandavi. we worked together at the brookings institution. not long enough. he worked to go to be director of the population and preventative health model group at the centers for medicare and medicaid innovation. cmmi, as you know is working with providers and communities

and everybody they can find to work with in testing new payment and delivery models to achieve the goals we're talking about today. and darshack has a special announcement. >> thank you. it's a pleasure to be here. and maybe the way i can start the discussion is with context. so as people have said, everybody agrees that an ounce of prevention is worth a pound of cure. so why is it so hard for us to focus on that part of prevention? i think a little historical context is valuable. 40 or 50 years ago, why did people see care at hospitals and doctors? it was things like, you know strep throat appendicitis, car accidents. it was all these kinds of things that actually required fairly acute care in a somewhat emergency setting. and our payment system evolves in response to that.

so oyou think why do we have medicare part a and part "b." part of it has to do with the ways in which we decided to pay for care long ago. as the years of v gone by, the nature of illness has changed dramatically. we don't have strep throat anymore that's a real major public health problem. that was the leading cause of rheumatic heart disease that was a life long disabling condition. and the entirety of the u.s. supply was used up in treating a singhening person single person. clearly we have mast everied those challenges and this is true of every clinician. when you go to a hospital or any center today you see a dramatic shift in the types ofal illnesses that cause significant medical care. we don't see children who are disabled by major infections in late childhood. we had vaccinations and antibiotics that took care of that. we've dramatically improved

traffic safety. we have fewer accidents these days as well and the list goes on and on. i make this point because even though the nature of illnesses change from acute illness to really today being chronic complex illness, two things have not kept up. the first is the payment system. we continue to pay for things in a piecemeal fashion. every time you go in you get a fee-for-service reimbursement. and the way to articulate this is we know the price of everything and we don't know the value of anything. in the ways in there we pay for health care. the second thing is that the ways in which we train our;e05m most skilled caregivers haven't also kept up. so you have a situation where yes, we have highly trained surgeons. i'm a pediatric cardiologist. we have highly trained subspecialists and yet when individuals end up seeking acute

care, their needs are extremely complex. they have social needs emotional needs, housing needs, all these other problems. again, because as a society we've been so good at dealing with the low-hanging fruit that now we're left with these much more complex problems that require greater coordination. so how do we move forward from here. we can all agree that prevention saves lives and also safs money if you value life in a certain way. so let's think about how we have incentivized prevention. i worked a met care and the lens through which we view the world is one where we can influence the world. so you get what you pay for. in other words, every system can give you the result it gets. so the ways in which we pay for care, we believe, have helped create the system today. so let's think about prevention. we all think that fewer cases of breast cancer is a good thing.

so how do we incentivize it? we pay for mammography. and when individuals say, well, look, we immediate to have that much more widespread, we could do a better job with doing prevention, the answer is well let's make it easier to pay for that mammogram. let's reduce the co-pay let's eliminate the co-pay let's ensure we have universal access to care. let's do public media campaigns that let people know you should get this kind of care. all good things in many ways. but does it in some way incentivize the end result which is we want people to live longer and healthier lives free of breast cancer in the first place%8:ñ[4 and if they are diagnosed with breast cancer do we invent vise long-term outcomes in any way? many have argued the answer to that question is no. so several years ago those of us who were involved in paying for medical care said, well, look we've just paid for these things and never demanded any quality in return, what can we do about that? so the idea that was come up

with is straightforward. i'm sort of embarrassed when i'm with economists when i explain how fundamentally those of us in health care are. the idea was simple. we'll just pay for performance. in other words with we'll ask doctors to click these buttons on a computer to show they're doing mammograms on patients. if you report that, you'll get a bonus. same thing, if you check blood pressure -- you have to do that now -- you click a box on the electronic medical record that goes through some black box system and you get extra payment at the end of that. this was like in -- like after we discovered dna and cardiac heart bypass. this is the best we could come up with. and this was like five years ago. [ laughter ] so i think this goes to show that we have a great deal remaining in terms of sophistication and how we can use what we understand about incentives to pay for prevention in much smarter ways.

i want to talk about at least one of the ways in which we're trying to move forward now. rather than continuing to pay for the fee for service system, we at cms and much more broadly at the highest levels, many of you may be aware secretary burwell earlier announced national goals to move from for for service care -- fee for service care to valuing payments. this is a fundamental way of shaping how we pay for care. so rather than paying for what we do, we're paying for overall cost of care. in other words we in medicine to some extend are learning to survive in the confines of having at least some budgetary responsibility. we all have to do that in our daily lives so we're asking us to do that with our health as well. the issue is that moving from volume to value in the early

stages incentivizes the short term width. you want to learn how to do that cardiac bypass surgery better so you can realize that gain in a year or two. you want to focus on how to do joint replacements better. congestive heart failure, you look at the big-ticket items that give you rapid value. clearly preprevention doesn't -- when you think about reduction in type two diabetes, obesity depression potentially, mental health, early childhood achievement, all of those things are undervalued through that strategy. so the question we're asking at cms, i imagine across the health care is is how is it that we can take the traditional ways and these baby steps and move it towards value and prevention. and i want to announce at least one way we're doing that today, one example of how we might think about this issue. this was announced earlier today by secretary burwell in boston

at the white house conference on aging and i want to describe it in more detail and i'd like to talk about -- i have two kids and we watch american"american idol" "american idol," and -- actually, we watch "the bachelor bachelor," too. there's a method to the madness. why is it that show fails to produce durable marriages long term? that's the long-term end point that you sort of are supposedly incentivizeing incentivizing, right? what they incentivize is having a lot of viewers. we pay for medical care the same way. so in a sense, we are all in an episode of "the bachelor," and

we want to focus people on looking at that point. we today announced the risk reduction model. this gives you a little bit of a view into taking this sort1jr rhetoric about we care about prevention and value it and how do we make it real is one example? it's this. when you currently go see your doctor, nurse practitioner they are in a value-based modifiers is what they call it, to make sure they take your blood pressure, and they actually get paid a little extra to get your cholesterol to a certain level and ask if you are a smoker, and that's what we do to prevent

cardio problems. when you appeal to peoples' good nature, that gives you motivation and financially we have not done a good job. we are going to change that. so instead of incentivizing every little bit, for those of you that see your doctor, the standard of care is that your doctor today based on the 2013 american heart association guidelines is supposed to take your age gender ethnicity and a variety of numbers your blood pressure whether you are a smoker or dieter, all that and they give you a 10-year score. we can see in the future right now and tell you in the next ten years what is your chances of a heart attack or stroke.

so that's a very valuable tool. that's a meaningful number. based on your individual profile in the next ten years there's a 30% chance you will have a heart attack or stroke not only that but here are the things you can do and reduce your heart attack stroke risks by this amount and you can take a bill and here are the pros and cons, and then you along with your provider can come up with a plan. what we are going to do is pay for that in medicare. not only that, your provider will be incentivized and get paid extra if they reduce the risk across the panel of high-risk patients. we are paying to make sure you get married, so to speak and we are marrying the incentives with the long-term out care we care

about, and we're going to be enrolling 300,000 medicare beneficiary beneficiaries. i will close with this. i think this notion, this is what scaresquares the circle. how do we pay for that? we break it down into things that actually predict it. we know with what percentage risk it's going to happen and let's pay to reduce that risk. this is how we can think into our way of designing payments. this is a broader structure. we could think about your risk and there is actually very good ways to proedict what your

chances of a hip fracture is. we can tell what your risk of breast cancer is. wouldn't that be better than saying all women over the age of 40 or 50 should get a mammogram. wouldn't it be better to know your personal risks and respond to that in some way. but what about risks of suicide? those are the things we can think about if this is successful. i want to say this is one way we are thinking very broadly about how is it that we fit in preventive incentives into the broader structure of allternative models. i look forward to hearing from all of our partners in the private sector and public sector in the ways they take advantage of the new way of paying for care and it does incentivize quality to come up with these

types of ways of intervention. i have a commentary in today's issue that was released online that describes the model in a lot more detail for those of you interested. >> thank you so much darshak sanghavi and alice. we will come back with questions from the audience, so if people have additional questions about that or other things we will come back to that. we are going to shift into our moderated panel discussion. i want to introduce our other panel members. jeff levyi, and he teaches health

policy and management at gw. to his left is dr. william dietz. he has a very long title. he was director of the cdc division of nutrition and physical activity and obesity for 16 years and is the mastermind behind the bright red maps between the changing obesity epidemic which i suspect some of you in this room are very familiar with, and pediatrician by training. at the far end of this group is my boss, bill hoagland. bill is the senior vice

president at bpc in charge of both, our full team and economic policy programs. he came here from cigna where he was vice president of public policy and most of his career was spent on the hill where he was director of budget and the appropriations of the then senate majority leader, and staff director of the budget committee. thank you for being here. jeff, i will start with you. we have talked about high-level frame works, big picture models and i want to go to the real world for a minute. more than probably any of us on this stage here at least you have the most experience with a number of the players on the ground who are really seeking to implement some of these experimental and new models of care that integrate clinic and community. the report that the task force

issued included some of those examples including one a very interesting one out of minnesota, and i would like to ask you to tell us a little bit more about what they did and why it's relevant here. >> thank you and i think this is an exciting opportunity to be talking about where prevention fits in our reforming health care system. i think it's also important that we have had a really good conversation and started a conversation around value and how we value things, and that it isn't just about costs savings but about better health outcomes and that the measure of our decision to invest in prevention isn't just determined by whether it will save health care costs. that would be nice, but in many cases it can, but it doesn't in all cases, but there is a reason to value prevention because it does bring us better health. i also think what we have seen in examples across the country,

and really many others across the country is a growing recognition in the health care system that in order to achieve the goals that darshak sanghavi was talking about, that improving value that you cannot achieve the goals within the four walls of a clinic alone. in fact, i would pause it to achieve the goals of the project that darshak described clinicians are going to have to reach outside the clinic because we are going to change increased physical activity and improve nutrition and reduce stress all of which are factors in heart disease risks, then that just can't happen in the four walls of the clinic. we have to recognize that it's both"v0 traditional health promotion and community prevention, but also a recognition that the need for

services is also criticalma5 u to achieving these health outcomes so that's a long way to saying, and then up in hen aopinion county they have been undergoing an experiment. they created a comfortable care organization for what is for medicaid expansion population, and they call it a sociable account medicaid expansion population. they look to improve out comes, and it's not just about accessible health care and they made changes there to reduce emergency department use by making dental care more accessible and creating a sobering center so they don't use the emergency room to sober up or the county jail for that matter, and they look at how well people can access social

services services, and recognizing if those needs are well addressed demand for health care services will go down as well. in fact, they have been able to demonstrate costs savings and expanding the nature of the services that they have provided. this is a model that works very well at a county where all of these different services are provided by the county and what we're hoping in this report, and endorsing this concept of an experiment around accountable health communities across the country is to see if in different venues this model can be replicated, and can we find the leadership and can we find the coalition builder and the backbone organization that brings these things together and can we create the data systems that make it a seamless process whether you are on the social

services side or care manager on the health care sides that people are getting the things they need. can we make this sustainable financially? because there is risks in it for the health system in reducing demand for health care because we have not completely moved to value so how do we help people through that transition and how do we make sure the investments are made in those things that help reduce demand for health care continue? we don't say we saved on health care costs so we can reduce on what they are getting. there are communities across the country where in different ways they are experimenting with that, and sometimes on that scare and sometimes on a narrower scale. we really need to examine those systematic and learn from them. >> i want to follow-up on your financing discussion. i think we recognize in this

group collectively agrees that this notion of integration between clinic and community is an essential ingredient and we need deliberate phebgmechanisms to make that happen and it's not going to happen by accident, and at the same time, however, those experiments are not going to have a life span beyond a little experiment if there is not a financing model, and i want to go to the budgeteer all the way at the end of the line, bill hoagland. bill hoagland always raises costs as an issue and sort of giving us the reality check about that's an interesting idea that sounds logical. how in the world are we going to pay for that? what jeff is talking about is

multiple sectors, all of whom have a shared interests in health outcomes, whether it's social services education housing, etc. and those are all different budget pockets within that county. how do we make the math work? what do you think is the most promising opportunity to integrate those funding streams and really develop a model? >> oh, lisel. first of all thank you for, i guess, putting me on the panel, and i feel out of place with all the experts here to the right of me. let me just say, let's begin with the fact that i agree that prevention, orientation of prevention are important as it relates to reducing costs in the long run. the difficulty with our budget

process, if you like, is that we appropriate the money for an activity that doesn't result in a benefit until sometime out into the future. we wait until you are sick before we go to the hospital and as you say, we are not reimbursing for that prevention. most of the prevention programs that we have in our federal budget, at least start out by being appropriated monies which are -- i get into the weeds a little bit, but these are annually appropriated monies, subject to right now a cap on the total amount of money that can be spent. you don't get the benefit of a reduction in medicare expenditures or medicaid expenditures and people doing the appropriations don't get the benefit of that. to make this work long term it seems to me you have to go back and quite frankly change the budget process in some way to

provide for the decision makers to be able to see that that, which is an investment like infrastructure education, it's an investment that will return a benefit to the nation, to the community, to the decision makers and to do that don't get, again, too far out here on this, but i believe the time has come to change our accounting systems in this country so we have almost a present discounted value, we invest the money here but can score it on the basis of what the benefits are today. that way at least if we can't change the cash-based accounting system at least we can let the decision-makers know if it's based on hard evidence and the word hard is difficult for me to say, but hard evidence that will

return on the investment then the decision makers can make their decision a lot better and that would be a way to integrate prevention into the process. >> alice, do you have something to say? >> i have a question for jeff. before we start replicating how do we know it's successful? are they actually reducing prevalence of disease or do we have a set of health indicators for the county that will improve or better yet to pick up on darshak, do we have a set of long-term probabilities of various bad events that it could

be aggregated, and if we did, then the answer to lisel's question wouldn't be so hard. you could then say we will actually reimburse this county for the things that are shown to improve those indicators. >> so they have demonstrated improved outcomes and they demonstrated reduced costs, but i think there are certain aspects of this experiment that are unique, which is why i think in the report we're not talking about taking this national, but actually going to the next stage and trying it out in a number of communities because the nature of the health systems and the infrastructure in different communities really varies so i think we are not at that stage yet. it would be to bring it to scale, because i don't think we know enough about it yet and i don't think we know enough about the sustainability of the financing model and we need to

be careful before we do that. i think it's one of the more promising examples. i would like to add something in terms of what bill was saying. some of this is a scoring problem, and some of this is also, when you think of this notion in a sense of integrator or braiding together -- let's not say integrating but braiding together various funding streams in the local level that's is less a scoring issue and more how can federal programs get out of the way of communities who want to be creative? i think that's part of what happened in the county because it was the government that was taking the risk and the county runs each of these programs. and yet there are communities where people want to come together and say, let's do -- let's coordinate our health dollars and housing dollars and our transportation dollars and our education and so on, and yet

the federal reporting requirements make it very hard for communities to come together on that, and that is not a budgeting issue or a scoring issue, it really is just a practical issue of how we can not just on the health care side but in the programs across the federal government get out of the way of these experiments. >> so jeff, to go back to alice's question we are not ready and we have some indications, but we are not ready to call for a spreading and scaling of what is happening, but what is the mechanism for taking us to the next level? >> i will get to that in one second. i think there are other models and there are some communities where they are bringing -- focusing less on the health care side or on the population wide, and others are looking at particular conditions and each of those models are worth

testing out to see to see if they work or not. i think the answer is, and darshak can probably speak to this, there is a notion so we can test it in a variety of communities and do the rigorous evaluation that i think is important. that said, doing it under the umbrella of cmmi has the restriction, i think, of looking at improved health outcomes and lower health care costs, both of which are really important, but when you are doing a more integrated approach to both health and community prevention and social services, there are other things that we need to be measuring that may be of value, but, again getting back to the constraints of some of the scoring requirements are not necessarily something at cmmi would be measuring. >> there are multiple layers here. one way to formulate, and the

problem is to say prevention is largely an issue and there is another layer, and to add what jeff is saying, i would just say as i mentioned before, i would challenge people in the room to say how many of you have had your ten-year cardiovascular risks. i assume you don't have significant mental illness or alcoholism, and if you do you are functional enough to be here today. one of the things we think about is ask yourself how many of you have struggled with being overweight and how many of had high blood pressure and how many of you got a colonoscopy once you turned 50? within that framework, let's think about today there are ten fold variations across the

country in rates of bypass surgery that are not explained by the access to health care. these are major problems and the ways in which we deliver care directly from the clinical system. one of the things i don't want to be lost here is yes, we actually in our group are developing several models that address social detourerrents of health. it's not just about value of socioeconomic development, and i would say this is a complex problem. as i said, if you have struggled with being overweight, ask yourself, is the problem that you don't know that's a good thing? is the problem that you don't have access to health care? sit that you actually don't understand that a big mac is bad for you? i don't think so. i think let's sort of actually look at that level. what is it about the health care

system and how do we structure it in a way that gets people to be benudged along those areas, and those are discussions we also should be having so just to add again to that layer. >> we are talking now about on the ground experiments that contribute to our understanding of how it can work in practice to actually roll out a system that integrates either clinic and community or health and public health plus other social services and that's where it gets even more complex and complicated. there's another area where we are getting evidence. i want to switch gears for a minute to the research questions. the other part of what the task force focused on was the need for better understanding not just of the interventions but also on the costs implications of those interventions. william dietz brings his

expertise from the cdc and government sector, and the cdc is collecting data on all kinds of things all the time, and also the academic community. i would ask if you talk to us about the state of what we know and what we don't know? i think there's a sense from some detractors if you will, we don't know what works and this is very terrible and we don't know what works, and on the other hand there is the issue that alice raised where we come up with strategies that allow us to take action in light of the uncertainty. if you could talk to us a little bit about both what we know and what we don't know and sort of from an academic or research perspective, what needs to happen to help us better fill in some of those gaps? >> well thanks lisel, it's a

pleasure to be here today. the cdc has a number of activities that relate to the development of evidence about what works in community-based programs. starting with president obama's cppw program communities putting prevention to work and moving on to the community transformation grants, there has been a big investment in community-based interventions aimed at chronic diseases most notably tobacco use as a risk factor and obesity and physical activity. and that has provided and is providing a rich source of information. one of the limitations of those data is the lack of very stringent evaluation of those programs mostly because there is an investment in developing the program but not so much investment and knowing whether the program is working or not

but cdc for years has run a task force on community services which aggregates data from a variety of studies and makes conclusions about whether for example, changes in communities promote physical activity and changes in infrastructure for example. another source of those data comes from substantial investments made in community-based programs and early care and education centers, and schools and communities. we held -- we were part of a conference of evaluators of those programs looking at which of these were most effective at preventing childhood obesity. most of those programs have praubgs mull data, and whether those behaviors change behavior

is a much bigger challenge. some of the critics of the programs have challenged what we call evidence. the standard for clinical programs or clinical evidence is randomized controlled clinical trials. those are not easy to do in communities. we have to use alternative sources of data, and a recent iom report provided a variety of strategies for aggregateing that evidence. and the other thing missing that was eluded to is noting what the interventions costs, and in the field of childhood obesity it's costly because you don't see that until 20 or 30 years later, so how do you assess cost-effectiveness. there is a really nice program going on under the leadership at the harder school of public

health known as choices. it's an achieve ration for childhood obesity intervention cost-effectiveness studies. they have taken 40 different interventions aimed at childhood obesity and began to put costs on the outcomes of those interventions, and the metric that they have used is the cost per unit of bmi change because you can't put a financial cost on that. so that is one issue, and what we suggested in this report, intervention studies, clinical and community intervention studies are required to provide the costs so we can begin to get more information on what is not just working but what is the cost of what is working, and that might allow us to compare the clinical interventions with the risk factors and the

community intervention which is changing the sodium content of the food and the availability of fresh and helpful food. i also wanted to come back to the other gap which i think the emphasis on community programs emphasizes, and that is clinical care and public health are siloed and we mentioned integration, and integration is not an easy matter. first of all, as jeff has said, who pays? how do you begin to incorporate a payment system that rewards community systems which are reinforcing the types of strategies that is being proposed? even if you can reimburse how do you assure this kind of cross communication between community systems and hospital systems? we know that the electronic health records are often not

enter compatible. how do you insure communication? most of all who does this? who are the integrators? one of the most important characteristics of the integrators is trust, and a notable person once said that change moves at the speed of trust. unless we are able to break down these silos between clinical and community services and unless we develop a common vocabulary and set of goals we're not going to succeed. >> i want to pick up one thing that you said. we at bpc think and talk a lot about decision makers and what they need in order to make decisions. we are pretty much all in the realm of limited financial resources. so decision makers are making difficult decisions among

competing priorities, and they need evidence in order to make those in a rational way. to pick up on your point, bill, emerging evidence that allows us to understand the context and the relative costs of the different interventions and programs, i think is extremely important development and helpful to decision makers. i can't help but transition to one question about the congressional budget office because we have a former director of cbo and a former staffer from cbo and a lot of the discussion about evidence some of the discussion about evidence is targeting decision makers at the congressional budget office who are trying to evaluate the potential costs of a certain intervention. i think if i could summarize the task on cbo it would be cbo is important but not the only game

in town. we wanted to make sure we talked explicitly and deliberately about what cbo needs in order to make recommendations to the hill and at the same time jeff eluded to the scoring of prevention is not the only way to think about the value of prevention. let me ask you, bill, as a budgeteer, and i hope i am not getting fired later for asking these questions, but what do you think is the bottom line in terms of what cbo needs? how should the public health community be thinking about cbo as an opportunity? >> i think you should ask the first director of that before you ask me. i am sure -- this is going to sound like a bureaucratic response, and as a former cbo staffer, but it's resources, honestly. i know it's a throwaway.

the need to weigh as part of this activity, and lesil and the staff, we met with cbo staff and i was shocked at the number of journal articles they have to go through every week 1,000 journal articles, if you can believe it just to weigh in. i concluded out of that discussion what they need is a watson ibm program to narrow it down and find that evidence that isçwo1 scaleable at a national level. i know it's a throwaway, but they need resources if they are going to translate this into actual good evaluation of the policies put forward. but i do want to pick up on something that jeff said though. the problem is and bill, too, to some extent, the problem as i

see it is prevention is not -- shall i say homogenous out there in terms of the communities. in some communities one intervention could work better than others, so it's difficult at the national level to pass national policy that could be replicated in terms of the cost estimate. >> alice? >> i would second bill's feeling the congressional budget office needs more resources to evaluate the evidence because the evidence on whatever it is, but on a health intervention or prevention intervention it's getting to be voluminous. but that said, what they really need is convincing evidence and i eluded earlier to some of the

enthusiasts of prevention who would love to pass a bill that says that for example, we should make available to every county in the country, and there are several thousand of them, resources to do what the county is trying to do. you can draft such a bill and eventually it would, if it got out of committee, or even got serious consideration in a committee, get to the cbo and say what would this costs and what would the benefits be? the costs wouldn't be very hard because you would specific what that was to be, what you were going to give all these counties to do this thing. but what is the benefit?

they would be driven back to looking at hen aopinion county. can we say that spending this money improved their health. if you can definitively say that and you thought you could replicate it in several other counties, then the problem would be simple but neither is true. you don't have the evidence about hen aopinion, and you are not sure what has made it possible for them to at least get a start wasn't tech -- peculiar to that county. that's what cbo has had to face and i think they do a pretty good job. >> i think there may be more evidence out there than we are accessing and so this will be my appeal, you know, and bill mentioned communities putting prevention to work which was part of the stimulus package,

and it was in hundreds of millions of dollars worth of investment and community prevention programs that was evaluated, and those evaluations have not been released. community transformation grants was supposed to be a five-year program and stopped after three years, so it's hard to do a full evaluation, but there was substantial evaluation money put into that. we have yet to see data from those. i think there is also an obligation on the part of federal agencies who are investing hundreds of millions of dollars of taxpayer dollars, and who have been directed to do evaluations to release those evaluations -- >> yeah, even if they are negative. we need to know that. >> we need to know that. that is not always the case on the budget side. we want to know what worked and

what didn't so we are not replicating things that were not successful. what is wonderful about communities in the grants, the partnerships to improve community health is that while they have the same targets communities are taking varied approaches, and evidence-informed approaches reflecting the needs in their communities. but if we are not releasing what we are learning from that then we keep redesigning new programs in the dark, and you put aside cbo needs, and it's not a wise investment of taxpayer dollars. >> but it would help cbo to release. >> uh-huh. >> and we discussed waiting for cbo is like waiting for -- >> [ laughter ] >> i am not as familiar with cbo as others, but if you are nursed

with randomized controlled clinical trials how do you settle for community-based data which is rarely based on a randomized trial. what is the level of evidence necessary to convince cbo. to echo jeff, i think there are other mechanisms that we are and ought to be pursuing at the local level through the community benefits initiatives of hospitals which we need to wrap in and there are mechanisms in place through the affordable care act to direct those hospitals to invest in community benefits and to do community health need assessments. likewise, darshak sanghavi, this is a question for you, it seems to me more flexibility on the part of medicaid to fund these kind of pilot programs that jeff has described and certainly the ctg are implementing would help

to move the field forward, so what is the likelihood that would happen? >> broadly speaking, we brought up with the county, and for those of you not familiar, this is simple at its core, you take all this money that is going to pay for their health care at the state level and you give it to the organization and you wipe your hands clean of that population. their job is to deal with it. they are the hardest and most complex patients to deal with and they are charged with doing that. those patients are automatically enrolled in the program. you don't have to go out and find everybody, they are yours. and there are governmental structures of data sharing not present in any other communities. the state has been very generous. while certain savings have materialized, they have not asked to pay that back. thrb there is a certain amount and

they keep that and so those are the features in that county. i have two kids, and one kid i give $10 to and he does a good job, and the other kid, he buys comic books and not responsible for money, and this is the problem we deal with. freedom is good right? we believe that. we want to give flexibility however in health care there are big dollars involved and not actors can be trusted. the question is, at least i think about it, if it's so great why doesn't it exist already right? this incentive strongly already exists and part of it is because we as a nation, and as patients ourselves are still uncomfortable with giving that much freedom away or freedom without necessarily asking a lot of accountability in return. how is it that you measure that accountability? we talked about having population health or clinical

matrix, and for those of you that go online go to hospitalcompare.com. patients often feel that data gives them what they care about. part of the other issue is yes, we want to move the nation and that's what moving to value-based payments is all about, and we think it has to be done very deliberately and although the pace may seem like we are -- why don't we directly pass a resolution to give everybody payments, there is a downside to that and i think this is one of the reasons we feel doing it in a somewhat more studied and deliberate manner is going to be better for most patients. >> i agree this is not a question of throwing the money out there and i don't think it's accurate to say that medicaid manage organizations

can do what hen aopinion is doing already. they are bringing all sorts of social services resources and nonhealth resources to the table that then get better integrated and your typical medicaid management association doesn't have the resources or the authority or the capacity to do it. so that's where it's fundamentally different. >> that brings us back, i think to where the task force ended up. this exchange really illustrates the issues that the task force struggled with and the reason they focussed on these very concrete recommendations for, for example, calling on cms to model, not to scale hen aopinion, but to model those examples so we can in a deliberate fashion uncover the elements that need to be there and the financing models that could be tested and proved so that we can spread and scale in a way that relies on -- so it's almost as if they are priming the pump giving us a little bit

of examples, but within this task force there was no call for, yeah, great we are done and let's move ahead with this but rather what are the mechanisms and tools we have access to like for example, innovation grants and etc. that can help us responsibly understand the attributes of a new model moving forward. i want to get to our audience questions. i want to ask panelists before i do, if anybody has a burning additional comment about the conversation we have been having? >> only to mention in passing that a previous study we put out a year ago here called training doctors for prevention-oriented care, and we have not talked about that too much either, but that was headed up by secretary dan glickman. >> yeah, when you talk about

trust and community intervention, that's part of it of how you retrain the clinical community and you recognize people in the community are their partners, and that can be a very important piece. the clinician was told you will have much better outcomes, and cms is holding me accountable for reducing falls among the elderly. how do i find those programs and feel confident in referring my patient. in massachusetts the healthdepartment developed a information base, and so there is a information loop going in both directions. i think just as importantly, the clinician can feel confident because there has been a third-party validater of those programs and you are not just

googling fall prevention programs. >> it's important to mention there is as much mistrust from the public side to the clinical side? >> yes. i will open it up to questions, and i think we have a couple people with microphones if you could identify yourself and ask your question i will -- can you pass the microphone to this person? thank you. >> i am dr. darryl roberts and an am an evaluation scientists for patel memorial institute and a nurse for 25 years, and worked a great deal of my time in home care and public health and wurbed inside hospitals. recently i attended a meeting held at the national quality forum where a representative from aca asked a question that i thought was poignant and in some ways kind of wrong, but it makes sense. if all of this prevention works

and it should how are we going to keep our hospitals full was the question? it's a bad question but if you think about it the question underlying it was how do we keep all of these people employed and what do we do with the cost shifting that is going to happen because of prevention? basically how can i work myself out of a job and yet still keep one? >> alice? >> that's a good question but i don't think the answer is really as hard as it sounds. the answer to how are we going to keep all hospital opens is we're not. we're going to convert some hospitals or hospital wings or whatever to -- as it has already happened, as you know to outpatient care and possibly to other things that have to do with prevention.

and so what are we going to do with the buildings is not so hard. the difficult -- it really is difficult to get hospital administrators to say you are telling me that i ought to encourage things that give me fewer patients in my hospital, and that's true. that's going to be a long road to helping them see they could preside over a different and varied enterprise but it's not going to look exactly like the hospital they have known and loved. one of the things that helps answer the question, what are we going to do to keep health care workers employed is we're in a situation in which no matter how

much prevention we do we are going to need more health care, because of the demographics, because we have this bulge of older people and older people are sicker even if they have been into good prevention. so i don't think the question of are we going to have unemployed pediatric cardiologists is a very serious one, but we are going to have to retrain some people and train new people to -- in the skills of prevention. >> i would say this is disruptive not just on the health care side but also on the public health side so we are going through the major transformation and roles are changing and it's not like there's not enough work to go around but the nature of the work that everybody is going to do, and 10, 15 years from now, somebody else sitting here will

be observing the nature of the change not just from the health care side but on the public side in terms of who does what and how. >> and let me provide some of the thinking. one model you might be interested in, maryland, we actually are doing this right now, so the way maryland works for those of you not familiar, hospitals have a fixed total costs, so it's complicated as all of these things are, but the bottom line is that you as a hospital cannot make a lot more money by just doing more anymore. you have a fixed budget. so suddenly think about the incentive that does. you used to drive by the hospital, emergency drive time is five minutes come on in. why would you do that? we paid a large amount. now that we have a fixed amount we don't want to see you again.

suddenly hospitals are investing in mental health clinics in their community and they themselves now have the market incentive to do exactly what it is you are doing. this model, it's complicated and we are evaluating it and there is always issues but there is a focus that we are trying to replicate this if other states are interests as well. these are the kinds of steps we are taking to address exactly this kind of problem. we want the market where possible to take care of these local needs and not have us impose it from the outside. >> i would like to address something -- >> identify yourself. >> i am allen roth and i have done quite a bit of public health work through my professional career. there are some biases that exists in terms of prevention of

substances that could have a very big impact on prevention but the biases have put these down, and i bring up one that is like vitamin c. and people will tell you that has been disproved so we know that that is not really the direction to go and then you find out, and i am sure this will be a surprise to many of you, that george washington university medical center has a vitamin c clinic. they will all tell you a lot about the science of vitamin c and why we should look at it. let's take another one which is a powerful steroid hormone for which there are 35,000 journal articles and yet this substance, vitamin d, is not talked about much in terms of real prevention

which the sun could give us a lot of help in that, but then the determinermatologists have given us a story that we should not have this exposure and a lot of health problems have resulted from that. i am sure you want only reasonable exposure, but where is the information getting out to the public. so in things like this where biases have crept in, and there are those that know the science like vitamin d at boston university medical center, we point to them. >> thank you. >> so it's there. >> yep. >> can anybody address this area and have you thought about it? >> i think throughout, you know, we have -- there is never going to be definitive answers on a lot of questions and certainly our answers on nutrition are shifting over time but i think that, you know, the right policies are made based on the weight of the evidence and institutions like the institute

of medicine bring people together to make those judgments. as with anything that we do with medicine and public health, we go on the bases of the best knowledge they have with the acknowledgment as new data may become available we make new and changed recommendations. >> alice and i were in a conference yesterday and something was brought to my attention, and it's called the white hat bias which is the analysis that comes from pearyer peer reviewed articles. the point i simply make here we probably need to go outside for the discussion was yesterday to look for hard evidence besides our peer reviewed academic

articles for the determination of what should be pursued in terms of our atphalnalyses. >> we have another question in the back row. >> i am with the american association of natural pathic physicians and we are trained in prevention and wellness. i guess my question is for lesil, perhaps and i was here nine or ten months ago and i believe there is another bpc task force and it's not wellness for me but memory retention, and that task force is an employer task force and i remember there was a chairman and verizon is represented, and coca-cola among

other groups, and when you talk about community support, support in community intervention and data collection and tracking is there a synergy between these groups? you have guys talked and do you foresee a role for employer based or employer-based incentives because those are real and can be made quite real and they are not bound by the scoring rules that in 29 congress. >> thank you very much for the question, and i will make two comments and see if bill has something to add. you are correct bpc has supported a council on health and innovation with the ceos you described. they looked at ways employers could improve health in three buckets, and one was having to

do with the health of the individual and one was the health of the community and one having to do with the health care sector itself and one of the ingredients of the conversation of that ceo council was precisely that the role of evidence and the role of the private sector in helping to contribute to the growing evidence base, so i think that a charge that they are very mindful of and aware of the role they can play. the second thing i would say is in terms of employers reaching out to the community that is again, another place where there is a very powerful opportunity i think, for big employers. i think collectively that group employs a million people in the united states to make a real impact at the community level going forward. bill, i don't know if you want to add anything? >> you left out bank of america and another couple large corporations involved in this, and that's ongoing and if you walk around after this is over with you will see a number of

the bpc staff with their bits or something else because they launched a major effort here, all those corporations in a challenge in terms of physical like to point out i have the very pleasant responsibility of overseeing the health care in health care area here. that's not just liesel's prevention. so we have the health innovation, we also have health cost containment. in some ways interestingly enough, what i find is the -- i'll be careful how i say this to my boss. the silos exist even in a small organization like bcp are the same silos that exist outside. how do you integrate prevention, health care cost technology? we're going a great job of integrating here but i want to say it's a small microcosm of what i see outside as we go through these activities.

>> i'm dave morgan. i'm visiting from the united kingdom. we have a national health service and they're delivering programs that identify people at particular risks, share information, encourage doctors to focus on at-risk patients but i walk across my own parking lot to my own doctors, there are heavily discounted candy, major manufacturer advertisers, the joy of eating lots of chocolate. heavily discounted alcohol and even diet foods with very high levels of sugar. could i ask, what is the evidence and how do you measure how much and at what cost good efforts are being undermined? laugh lav. >> i'm not sure that i know the

direct answer to your question but one of the interesting phenomena in this country is now that we're at a plateau with respect to obesity rates and decreases in our youngest children. that coincides with the number of national changes which include reduction in the consumption of fast food, pizza and sugar drinks all of which are not well compensated for when someone consumes them. that's probably a consequence largely of new information and i think it's fair to say that michelle obama has played an important role in increasing awareness. and even though the limit on sugar drinks in new york city failed, the press that accrued to that initiative had an enormous impact on recognition of the role of sugar drinks in obesity. i think the challenge here is that -- and i think the single most effective thing that i think we can do is pass a sugar

drink tax of a penny per ounce which happened in berkeley, it passed in san francisco but didn't have the requisite two-thirds vote to direct those funds more directly. it happened in mexico. it's clear that berkeley is already showing an increase in revenue. that there's already a decrease in the consumption of sugar drinks and in mexico. what we need are more data on what health impact those challenges have. and all of that is before we've really begun to substantially change the environment around food and a number of institutions. school have changed as a result of the healthy hunger-free kids act. there are new -- i think the child and adult care feeding program which is about to emerge from usda is going to set standards for early care and education. the one area i think we -- there are two problems. one area we haven't been successful with is increasing

physical activity in the population. o other thing that is more than worth mentioning, it's a significant problem is that although we're seeing decreases in the prevalence of obesity in municipalities and states, those are largely limited to the white population. as a result, the disparities in obesity are increasing in those communities despite their success. and unless we come to terms with those challenges, the disparities with respect to obesity, i don't think we're going to have long-term success. some of the programs that we've discussed have not been necessarily ethnic-informed or ethnic specific. i don't think we yet know how to do that well. >> and it isn't just sugar drinks. it's smoking and other things that have become markers of

class and ethnicity, unfortunately, in a way that they were not before. >> i think to pick up at least a little bit on that i'm very optimistic about this. not so long ago physicians were advertising cigarettes. if you just sort of have a little bit of historical perspective, there's a tendency for -- teen pregnancy rates are lower than they have been. you said obesity rates are significantly decreasing, smoking rates are lower than they have been in a very, very long time. so in many ways improvements have occurred. so it's in many ways are you a half full or half empty glass person? epidimiologic trends show the system for all its flaws does seem to respond positively in the long run. despite the epidemic of obesity, we have the lowest risk of cardiovascular mortality we ever have in the united states. the other thing that's important

is i think i made a comment that we in medicine knew the price of everything and the value of nothing. the key thing to point out is many interventions as dr. dietz pointed out are not ones we sat around the table and said wow are we going to calculate the precise cost/benefit? they just clearly made sense. at least that's how i would think about it. these are political fights to some extent. why do we do early childhood education? yes, we can fight about the economics of it but we can also argue is it an ethical responsibility? is it the right thing to do? we shouldn't lose track of the fact that we also need to fight these battles politically not just an on economic level but one that does appeal to equity to opportunity for all people and health, i think we can all agree, is something that has universal appeal. yes we want to make sure we do things in a financially responsible manner but all this call about randomized data, we sit with a lot of data it's

really member rousenebulous a lot of times. even when you got the data together. so the right thing left is what do you believe is the right thing to do to make sure you don't make those decisions. >> i would like to end on that "cup half full" high note and to say we have focused a lot up here on the federal policy levers for change that are important and those are important. we do need more data and more sustainable financing mott dells, we need better connection between the clinic and community but this is not top-down stuff. a lot of this is homegrown ingenuity people are figuring out on the ground. many of you who are watching online, on c-span, on twitter are people on the front lines providing care figuring out reimbursement strategies. if we are going to integrate the clinic, the community, health and public health we need all of us in this room to hold hands

and march forward to we look forward to working with you as we think about how to implement these recommendations and thank you all so much for coming. [ applause ] coming up live today, live coverage of president obama's remarks in california. he's speaking to the u.s.

conference of mayors in san francisco talking about the economic health of u.s. cities. we'll take you there live at 5:15 p.m. eastern. this weekend the c-span cities tour is partnered with comcast. to learn about the history and literary life of key west, florida. ernest hemingway wrote several of his novels at this house in key west. >> they bought this house for sale for $8,000 in 1931 and pauline converted this hay loft into his first formal writing studio. here he fell in love with fishing and the clarity of his writing, how fast he was producing the work. in fact, he knocked out the first rough draf oft of "a farewell to arms" when arriving in two weeks. he said if you want to write start with one true sentence. >> for a true writer, each book should be a new beginning where he tries again for something that is beyond attainment. he should always try for

something that has never been done or that others have tried and failed. >> key west is where president harry truman sought refuge from washington. >> president truman regarded the big white house as the great white jail he felt he was constantly under everyone's eye. so by coming to key west, he could come with his closest staff, let down his hair, sometimes some of the staff would let their beards grow for a couple days. they certainly at times used off-color stories and they certainly could have a glass of bourbon and visit back and forth without any scrutiny from the press. a sportswear company sent a case of hawaiian shirts to the president with the that if the president is wearing our shirt we'll sell a lot of shirts so president truman wore those free