i'll be a bit provocative here innovators prescription, grossman, in one section of that book he talks about participation in 401 (k)s, all this business folks out here is like 85%. participation in wellness programs is like 25%. >> that's exactly -- >> we're not doing something right. you know, reference to other books, how to change when change is hard by heath and heath, switch. driver path of the elephant we've got to figure out a way to smooth the path so that we are able to see groups of folks going down a better path. again, using 401(k) versus wellness. we're not there yet. one positive example to something george said about getting in the communities, we did a peer coaching pilot with 100 persons with diabetes, going back to diabetes and 100 getting usual care. this is a very high performing

group, so usual care is pretty good. the peer coaching group did -- got better results. so those are the kinds of things we're moving toward. again, thinking differently. the same old same old is not getting us a better health outcome. medicare star metrics, yes, but overall we still have much work to do. >> is there any -- there's so much talk including the talk right before this panel about the potential tech. i forgot the number of health and fitness apps, all of us together couldn't count them in a week. is there anything that you're using with the populations you serve that is actually -- that you are investing in and you see this is a tech tool that is making people stay healthy or controlling their conditions they have better.

is there a there there in your world? >> i guess i would have to say at this moment there's no silver bullet from a technology perspective that we've employed that we said this thing has changed everything for us. you know, we do have fortunately a much higher participation from our employees in overall health programs. it's approximately 90% worldwide. and we've done things differently than most people. so to the words of our first speaker today, we've got to think outside the box. our approach is we don't provide financial incentives for people to participate at all, to fill out questionnaires, biometrics, programs, there's none of that. we never have. the difference is that our approach is make something so valuable and the experience so positive that people will always

want to come back and always participate andern their trust everything we're doing and offering to them is truly in their personal best interest. behave and act with integrity that we're here as their health advocate. we've attached this to other things in the country which have had high participation rates so we would be successful. i would encourage people to use a marketing mind-set and to create value, to create participation. >> you know, the interesting thing about tech is bob at harvard business school doing a survey of experts actually asking the question what are the factors that drive health. the experts will overestimate personal impact helped by a factor of two, technology and personal care by a factor of two

to three. we as human beings want to believe we are in personal control of mortality when collectively we need to work on factors that help us determine collectively where that mortality moves. those are far more important than we would estimate. now, having said that, we've got a lot of apps and technology that we're deploying to try to help people track activity and motivate them to change their behaviors. but the science isn't in on that. we have a lot of faith. our research unit conducting studies to figure out where there is in some of that. on other in terms of programming and workplace bonus, we've got good data about impact for companies and company productivity. >> are the people who use those apps in the fitness monitors and trackers the ones who would be exercising and playing soccer anyway, or do you know whether it's making people do more or

they are enjoying tracking what they are doing anyway. >> i do see selection, i wear one of these, my heart rate around 79, normally 58. i must be a little bit nervous up here. just a personal observation, folks enamored of, going to the gym anyway and doing those things. we are working with clinical partners owner bidirectional data exchange. we've been looking at a variety of maybe not quite as much as health partners but application, tools in technology, certainly some of our groups are very invested in doing a great job with their patient portal and that kind of information, which isn't exactly an app. nothing that we've seen or observed or done yet i would say is very profound, proverbial

game changer as it relates to a wearable or something like that. bob, our keynote speaker earlier had insights and ideas. from our perspective, we haven't seen anything that's been profound. >> it's time to wrap up. i guess i just want -- my closing thought, actually shared it with them on the phone, when they first asked me to do a panel on health care investment, i thought it was people buying companies. it was just reading the headline about consolidation or antitrust, getting bigger, getting smaller, whatever. as i figured out who was on the panel, we had our before phone calls, it really is and i hope they have been able to show you a different kind of investment. it's an investment in the population that one way of getting these costs maybe not down to the way we really love them but a way we can manage better does have to do with thinking differently about what's health care, what's health, and how to invest in

what we've come to call population health. so thank you for joining us. so good morning. good morning. i'd like to first begin by thanking the u.s. chamber of commerce and u.s. chamber of commerce foundation for actually organizing the summit. today we've got the business community, health care community and policy community that all

together here. we don't often get together. we need to do more of this. it's really important for the future of health care. some of you my not know novant, so i'll take a minute to introduce who we are. we're a not for profit health care system comprised of 14 hospitals and 500 clinics and ambulatory sites that obviously provide advanced medical treatments throughout north carolina, south carolina, georgia, and virginia. in fact, we treat more than 4 million patients annually in those ambulatory sites. again, not for profit. just to know i have been with novant health 15 years, the last four as the ceo. so today we're here to talk about some important topics. the future of health care. you know, these days when i look at the future of health care, i describe it this way, that we're

redesigning a plane at the same time we're flying it. think about what i just said. redesigning a plane while we're flying it. why do i say that? let's take a moment and look at the state of health care. as you all know the health care industry is in the midst of dramatic evolution. affordable care act in 2010 has had a profound impact on insurers, doctors and hospitals. the national imperative is clear. we must improve the patient experience, improve population health, and obviously reduce cost. we must do this at a time when the demand is on the rise. you know, we have a rapidly growing senior population who obviously need the most care today. we have a group of americans newly ebb insured in our health system for the first time. so just with novant health's experience, the number of people

entering our system has grown over the six years since the law was passed. for example, again, we operate in states across those four states that did not expand medicate. for example, our office -- physician office visits are actually up from 3.8 million in 2010 to 4.1 million in 2015. no problem when i describe that, right? i forgot one important point, we must do that at a time when the payments we receive from insurance companies, medicare and medicaid are stagnant and declining. don't forget our payment structure is changing from one based on volume to one based on value. patient satisfaction and readmission rates are important factors in our revenue stream. we're all being held to much higher quality standards.

we're also sharing in risks today. and our ability to treat patients efficiently and effectively is what will allow us to succeed financially. all of what i just described adds up to a challenging business environment. but i want you to hear me. we are up for the challenge. again, we are up for the challenge. so i want to take a minute to explain novant health's approach to flying and redesigning the plane. this is an important aspect of what we've been doing. first at infiltrate ovant health we focus on treating the individual rather than the disease. this means offering new access points to consumer by expanding our providers' office hours and providing off hour visits to better accommodate our patients busy lives. it means using new technology to our advantage, by offering online scheduling options and investing in a patient portal

while patients can e-mail their providers, have video physician visits, review their lab tests, review their physician notes, schedule an appointment and refill their prescriptions. i'm sure many of you are participating in hospital and health care systems that offer these services. if they are not, perhaps the day you make come and join nochbt health. >> we conduct add study how they want to be treated value being treated with respect as much as quality care. that's a very important insight. people want to feel respected whether they are in a hospital or a clinic. we work hard to honor that wish by training doctors and nurses to empathize with compassion that delivers remarkable patient experience they deserve in a very authentic personalized way. second, we have invested heavily

in health care technology. we are big believers that health care technology is very important and we value it. we may be one of the minorities when it comes to this issue. we have invested 600 million in our electronic health record. we believe it's a great investment. it's helped eliminate errors. contrary to popular opinion, it's actually increased the amount of time our providers and nurses spend with their patients. we put -- for example, we put technology in the hands of our nurses and they go from room to room, patient to patient to discuss how each person feels, what the treatment plan is for that day. recordkeeping happens in realtime with the nurse and the patient together. this adds up to more time at the beside and less time at the nurse's station. in our case at novant health, this means 76% of a 12-hour

shift is on direct patient care in the patient room. so the industry average is less than 40% of a 12-hour shift on direct patient care. this effort also helped to improve the patient experience, helped reduce accidents and falls inside of our hospitals. it's reduced medication errors and been good for nurse moral. guess what, they get to do what they always wanted to do, take care of patients. third, we invest in the health of our doctors and nurses, because we believe in order to have world-class physicians and caretakers, we actually have to invest in them so we can deliver world-class care to our patients. physician burnout and nurse burnout is a significant and largely unrecognized threat across the country. despite the surgeon general recognizing physician we will

being as an important priority earlier this year. you may be surprised to hear that on average one physician a day commits suicide in this country. think about what i just said. one physician a day commits suicide in this country. and a recent survey by medscape, 50% of doctors feel burnout in 2015. 50%. i will tell you burned out physicians, burned out nurses are probably not delivering the highest quality care to their patients. that's why it's so important to make sure our doctors and nurses are in good health. so at novant health, we have developed a home grown program to help our providers address burnout and develop the skills they need in this new health care environment. since launching in may 2013, the

program helped 700 physicians and 300 nurses regain their commitment to the pursuit of medicine. let me share a story with you, one that really brings the importance of this program to life. a physician who completed our program recently wrote to me, sent me a text. i'm going to read the text to you. it says, thank you. you saved my career. what's really important is you saved my marriage, my relationship with my kids, and most likely my life. thank you from the bottom of my heart. again, this program is reengaging physicians and nurses and getting them back into why they got into health care. yes, these are challenging times. we're not alone in facing these challenges. every hospital, every health system across the country faces the same challenges we do.

we are making great progress. but i believe there are policy changes that are needed if we're going to achieve the aaa. as you know, we operate in an environment that is heavily regulated by federal and state level. the rules and regulations are sometimes contradictory and in most cases were written two decades ago for health care systems that frankly no longer exist. for example, current rules and regulations make it risky for doctors and physician assistants to collaborate on care, bars hospitals sharing electronic health record with certain outside physicians, it creates financial disincentives for care teams to follow best practices and it bars hospitals from making specific recommend as about which skilled nursing facilities to consider after discharge. even if we know, and there's data that shows, certain ones

deliver higher quality care. this crazy patchwork of rules and regulations does not serve the health care system or patients very well. we need policies that reflect the current environment we operate in that eliminate obstacles that currently make it almost impossible to deliver the affordable high-quality and coordinated care that is expected of us. we need updated modernized rules and regulations that support collaboration among hospitals and doctors and coordination of care that is essential to improving the quality of care. so at novant health, we support reforms to the anti-kickback law and stark law so that we can do the following, share electronic health records to improve care coordination, allow collaborative arrangements to coordinate care when a patient is discharged. reward a team-based approach

that includes nonphysician practitioners and provide assistance to patients to maintain their health when they return home. we believe in it so much novant will be working with hospital association and next congress to address these opportunities. we also believe there's room for collaboration among competitors. especially in back office functions such as information technology, revenue cycle, human resources, purchasing. in addition -- in addition to back office functions, we believe we should look at sharing in clinical enforcements with competitors and not duplicate efforts, duplicate spending. we believe we can save billions and billions of dollars, money reinvested in unmet community health care needs. quality improvements and population health. but today we're prevented from doing this under current

antitrust laws, which again were written more than 20 years ago for a health care system that looks nothing like the one we have today. this is exciting and extraordinarily challenging time for health care industry. if we're going to achieve national imperative improving quality, reducing inefficiencies and bending the cost curve, we have to be bold and innovative in a new way to deliver this care. we need policies that allow for this innovation to take place. these policy changes would impact health care systems across the country to better serve communities, realize national imperative to provide higher quality and at the lowest possible cost. meaningful change, especially in collaboration cannot move forward without these policy changes. in closing i want to leave you with a message that success is

possible. progress can be made, quality can improve, and savings can be achieved. novant health has firsthand experiences with this. for example by working with our team members and employees on health promotion and wellness initiatives, we put an emphasis on each team member and their disease prevention, disease management and healthy living. we created incentives for our team members and our employees to go to high performing efficient doctors for their care. and the results have been impressive. screenings are up, emergency room visits are down, physician visits are up. hospitalizations are down. annual physicals are up, costs are down. let me repeat that. costs are down. the money we spent object employee health and wellness this year is 10 million below

our forecast. quality can improve. consumer health can improve. we at novant health are proof that it's possible to bend the cost curve. thank you once again to the u.s. chamber of commerce, u.s. chamber of commerce foundation for hosting this summit, and i look forward to taking questions from the audience. thank you. [ applause ] do we have questions? yes. [ inaudible ] >> i will. it's a program right now we designed that's a three-day program. it does really a quick look at what really happens and how do people say you, in other words, as an individual, as as practitioner. how do you believe you see your self, how do others see you in your clinic, how do patients see

you. then we actually get into behavior patterns that either drive success or drive people away and drive chaos both in a clinic and in a practice and at home. and we look at the whole life. right now we're looking at how do we take that three-day course and bring it to where we can take it maybe in a shorter period of time but still give very similar results. thank you. yes? >> carl, great job. with the comment you made about having your employees go to high performing, high value, what's been the backlash. you have a large medical staff i'm sure at your many hospitals in five states. those that aren't on the list of being high value, how have you dealt with that political fallout? >> so we put a stake in the ground. steven, we put a stake in the

ground. what we said we were going to do is absolutely what we laid out. we offered incentives with lower co-pays, lower outfit pockets for our employees and team members to select those doctors. we've had some questions. the beauty of it is we've had physicians now working with physicians to help others get to that list of where you'd want to be that provide open access, high-quality care and efficient care for our team members. others? yes. >> well, the movement from pay for services to pay for performance in value, i've been on the quality alliance steering committee, et cetera. i don't want to get too technical, you can out technical me times ten.

how do you value services in your group, patient surveys, et cetera, revisits to the -- for retreatment to the same underlying disease, recidivism or what in a nut shell. thank you. >> obviously values we're all measuring. i'll start with the first thing we did is something very simple. in our group, we measured how quickly one of our team members could get inside and get an appointment with one of our doctors. we opened up access. so the first thing for us was did the patient -- did the consumer see it as value? those are the things we focused on. for example, these video visits, we actually have primary care offices that run a lot like urgent cares to keep the lower price points, lower options, so that if you think about that, we directly focus value through the eyes of a patient, through the eyes of a consumer. and through that we obviously have a scorecard that we monitor looking at how many visits can

we reduce, get people in the right place, right time, right price. that's how we're looking at value. >> just a quick comment, i saw it yesterday so it's fresh in my mind. patients, consumers, call them what you want, access, parking, courtesy, all the quality measures and all that stuff we pay attention to was like -- so the parking, access, courtesy, 4.6 on 5 and quality measures were .6 in terms of what the person perceived as being valuable. >> just the highlight, i talked about electronic health record. what i want to share with you, we have 700,000 active users utilizing our electronic health record today and it's because of the access points. our doctors and our providers are encouraging, you know, our patients as they come in. if you want to stay connected to

me 24/7, the best way is through the electronic health record. we've got people e-mailing questions. we have that constant video visit where it gets recorded inside the electronic health record and all of that is right there for convenience. i would tell you access is the key part for a lot of our team members to not only selecting our providers but to really engage in the way we need them to engage. thank y'all. [ applause ] ♪ ♪ >> what do you think of these

avatars. thanks for this important conference, bringing up important points in health. i'm thrilled to be here and give entrepreneurs startup perspective. our bodies are radiating data. since the beginning of time, your bodies have been radiating data. for the most part we've ignored these data until something goes terribly wrong. you wake up with a sore throat, achy back, then you start paying attention to taking vitamins and getting rest. or your physician calls you and says your cholesterol levels are through the roof. the data that your body had been radiating are now making you realize, well, i need to start paying attention to my diet and my exercise. but more recently we now have loads of gadgets and sensors and gizmos that can help us collect the data that our bodies have been radiating since the beginning of time, analyze it our selves and make improvements

to not only our wellness but our health without even talking to a health care provider. this is profoundly different model in health care where wearable sensors are taking us. and it really dove tails on two concepts, wellness empourm and patient empowerment. we'll touch on both of these in the next few minutes. think about what might be possible if you can take these data that your body have been radiating and make the most of your body and your mind. so starting with wellness empowerment, this is prior to things going wrong, you're all familiar with the activity trackers, fitbit, jawbones, nike fuels, some which are still on the market, some which are not. it's been ground breaking to get people to collect data from their bodies. these activity trackers are just scratching the surface with

where wearable sensors can take your wellness. stress is one of the most important trackers that people are wanting to see in wearable sensors. now we have trackers that can simply connect to your waistband all the way up to headbands that can help you with your medication process. all of these stress trackers are able to identify what makes you anxious, what makes you stressed, what are those triggers and how you can improve that. i like to call this quantified mindfulness. think about all of the health care parameters and challenges that could be improved simply if all of us are able to reduce our stress with sensors as simple as these. the others sleep. you may have noticed there are a lot more sleep trackers and sleep apps out there. everything from a free app that you can put on your arm or

pillow all the way up to more expensive sensors that can identify your sleep patterns. these products are telling you which nights you have good sleep, which nights you're losing sleep, and, again, the triggers that can help you improve your sleep. i like to think of this as sleep mindfulness. what's interesting is the irony that all this technology is what caused us to be stressful and lose sleep and now we're turning that around and using technology to bring us back to mindfulness, but that's okay. it's all about behavioral modification. sensors are really changing the way we live our lives. joann brought up a point this morning saying there are so many sensors on the market now, how do we make heads or tails of them. there is a website from partners called wellocracy that will compare and contrast tables out

there. this is one table about sleep sensors and devices. can you click on this website and identify which sleep sensors, health sensors and all different types of trackers may be best for you. patient empowerment is the second leg of this stool, or the buzzword, of course, is the consumerization of health care. the bottom line with the consumerization of health care is really disrupting the balance of knowledge between health care providers and patients. so for all the physicians out there, watch out. the patients want to know as much as do you about their health care. recently in a recent survey, 60% of smartphone owners in the united states use their phones to manage health. this is still in the face of privacy issues, potential hacking issues. customers and consumers want to learn about their health and collect those data that their

bodies are radiating either to help their own health alone or in collaboration with their health care provider. there are a variety of different health users out there. for instance we can now just snap on a sensor on the back of our phones and come out with an ecg of our heart health at home, without having to go into the physician's office or hospital and use the incredibly expensive equipment. we can identify our heart health at home with wearable sensors that can collaborate with health care practitioners. so doctors out there do you or don't you recommend these types of technologies? a recent study showed on the right-hand side in the red, 40 to 50% of physicians said they are recommending digital health and mobile wearable sensors to their patients. when their patients were asked, have your doctors recommended any of these sensors, only 4 to

5% said yes, my doctor has recommended. so there's a gap here, which is really causing a slow uptake of these digital health sensors to help the health care practitioner. now, the reason could be that there really is no approachable intuitive technology with actionable outcomes. perhaps the physicians would be more likely to strongly recommend these products or the patient would be much more likely to go out and try these products if they have actionable outcomes and they were easy to use. well, now i get to talk a little about my company. we've developed priya, a personal fertility sensor. it tracks a woman's core body temperature identifying subtle cohabitation that occur just before ovulation. when she's most fertile, it sends an alert to her smartphone.

the foreign factor is an intervaginal ring, just like all the rings on the deck market for decades. nova ring, they have been on the market for years. they are drug delivery. she inserts the ring, she has medication delivered to her and removes it at the end of the month. we've simply taken the medication out and put continuous temperature sensor in. she mares it a month at a time. she does nothing more than wait for that notification to be sent to her phone. yes, it can be sent to her partner's phone as well. so this is truly predictive personalized digital health medicine. it's also a subset of the empowerment story, which is women's health and women's empowerment. it's a very interesting time to be a woman in this day and age in history. and looking at the health care market specifically, the global women's health market is

scheduled to grow 4% in the next if you years. global market for women's devices is forecast to grow $2.5 billion in 2021. some of this has to do with the fact women are waiting later in life to get pregnant. some of this is fertility treatments and fertility devices but this is also due to the fact that women hold the purse strings in many families and women are now demanding that the health care system pay attention to their specific needs from a health care perspective. i was just recently asked to write a story for ink magazine that focused on the challenges to surpass the stigma that women's health is a niche market and build a business that benefits half the population. i've actually been in meetings when someone in the audience realizes our main product is an intervaginal sensor and raise their hand and say, that's for women, just for women. that's half the population.

our product can be used for women trying to get pregnant as well as women trying to avoid getting pregnant. so that's a pretty big market of the slice of the pie in women's health. so looking at different health care perspectives as not a niche but large market. luckily the important players are paying attention. although our product is direct to consumer product, we now have pilot studies with both aetna and kaiser. they know the importance of attracting and retaining women members into their organizations. and so sensors, i believe, will really accelerate personalized medicine. the promise of personalized medicine has been out there for since before my career in biotech started 20, 25 years ago with genomics, and we've been making progress but it's been slow. how do we personalize this?

use sensors. what we've done is impossible. we've transmitted core temperature from inside a woman's body to her smartphone. not to expensive property, hospital equipment but to the phone that she's walking around with every day. this is a graph of the raw data that we collect. this is about three weeks worth of data from a woman. as you can see, we're collecting circadian rhythm. that's what your core temperature does every day. this is one of the most personalized parameters of your physiology. you each have a very specific circadian rhythm. using core continuous temperature, we can predict a multitude of many of health care's challenges. did you know a couple of days before you start showing symptoms of the flu, your circadian rhythm temperature pattern shifts. this is even before you show a fever. so we would be able to identify

this shift in temperature and let you know that an infectio infectious -- infection is ensuing. on the flip side, an alert can be sent to the nurse's station. this patient is looking like they might require hospital sepsis, send an alert so treatment can be started two days earlier. or cancer treatments. there are numerous studies in literature that show when chemotherapy is administered based on your personal circadian rhythm, outcomes are significantly improved and side effects are reduced. it's simply the fact that physicians have no way of measuring circadian rhythm right now so they simply administer chemotherapy when it's convenient. this is an example of using a very simple sensor with a very simple vital sign called temperature to really overcome many of health care's

challenges. there are other personalized products out there as well. we've heard diabetes mentioned a few times today. so there are a multitude of dplu companies and insulin pumps, glucose sensors and insulin pumps. twenty years ago this would be bobble. we're now wearing a patch that shows personalized glucose levels and alters medication based on their personal glucose levels. this is for children as well as adults. we're taking care of the whole spectrum of patients with personalized medicine using sensors. so whether your sensor is experted like the ring or implanted or ingested, or worn like the glucose monitoring contact lens, these sensors are true personalized medicine identifying your specific data

that your body is radiating. so what's next? how do we get to health 3.0? i've got a couple of opinions so i'll give you my top three. these are just opinions i'm sure everyone in this room have their thoughts on how to get to health 3.0. number one we must desilo the data. health care industry collects data, physicians offices, hospital administrators, this is not allowing us to get a full picture of the patient or a full picture of the patient population. we for you have big machine learning and data analytics that help us predict many of health care's challenges but we must desilo data to integrate all this data into big machine learning algorithms. patient information at this point is not shared across providers. less than 50% of physicians in

the middle of this diagram can share their patients' records electronically with physicians outside their practice. how are we supposed to integrate a patient's own face of health without being able to share the data? but it's starting to happen. 3m and verily and ibm and apple collaborating for several years to consolidate the data coming from the apple watch. so we're getting there. my second thought is this must be evidence-based. now, for those of us that have been in health care and medicine for years, we know that the practice of medicine has always been evidence-based. when you talk to the technology companies who are being integrated into our digital health care space now, they have never had to run clinical studies or rigorous data analysis to show that the uber

app works or facebook is working as expected. so the rigorous data that's needed to use a technology for health care is required. one example of a company that's spearheading this just closed a $15 million round of financing. they study all these digital health technologies to identify which are showing claims and evidence they say they are. this is what we need in health care and medicine. it's starting to happen. jama, journal of american medical association actually did a study on the apple watch. i almost fell off my chair when i read this, but i was so happy to read it. it compared the apple watch, fitbit, basis and fuse to determine which one has the best heart rate monitor. pretty basic stuff, right? people are using these digital health sensors to identify issues with their health care. so these types of rigorous

studies are required to make these digital technologies evidence-based. so kudos to jama for publishing these types of studies. finally, collaboration is key. as i mentioned the health care side, the technology side, the fda and compliance and regulatory sides all need to sit at the table to make these digital health products viable options. and it's starting to happen. i won't read all of these but this is just a smattering of the really exciting collaborations we're seeing. senofi, google, apple, nokia, mattel, all these companies are partnering with top health care providers and research centers to integrate and bring together the right people at the table. but vision is essential, ip, intellectual property, for instance. tech companies talking about open source and sharing data, pharma companies used to patenting and keeping things

quite close to the chest. there must be some flexibility when we're talking about integrating data and technologies with each other or competition. phillips and qualcomm have recently collaborated, which is going to require phillips to branch out from their very closed phillips system they have had with data analytics and start sharing their data from their interesting sensors and devices. jim malt put it very well from qualcomm. the last thing a player wants is ten different one off solutions that don't interoperate and have nothing to do with each other. but the vision by jared jocelyn from verily said on duo, which is the diabetes program that n sanofi and apple collaborated on can sell insulin or novartis, nothing to do with sanofi, but the customer. the vision must be shared between health care and technology companies for these

collaborations to be successful. so in closing, your body is radiating data. now those data are in your hands. my clicker just lost it's self. so the question is what will you do with those data to become the best person that you can be. thank you. [ applause ] i've got 1:28. anyone? yes. [ inaudible ] >> -- count all this data you're getting. the biggest issue on a scalable way, and this also goes back to virtual health in the future, is what to do with that data and

they be how do i with on demand have access to somebody that can tell me what to do with that data. >> the next actionable outcomes. absolutely. that's why our product is getting so much interest is because not only are we collecting temperature data and showing it to a woman, but we're saying, okay, you're ovulating in two days. the action is either take one action if you're trying to get pregnant or avoid that action if you're not. we need more analysis of the data. to be honest, the issue there is the fda. of course we have to stay in friendship with fda. but a lot of these wearable sensors are trying to avoid being diagnostic. as soon as you become diagnostic you have to walk down the 510-k medical device pathway. as long as you're just telling someone about the aspect of their health, you know, here is some information about your sleep. here is some information about

heart health. we're just telling you your ekg looks like this. as soon as -- as long as there's no diagnosis, they don't have to walk down fda pathway. the 510-k process takes a little bit of time. as long as the fda keeps progressing on the digital health side of things, which they really are. they are coming out with more and more guidance documents, that will hopefully be reduced. that hurdle will be reduced. for someone to say, okay, you've got the sensor on. can you check your heart health. come out with ecg, but they don't want to say, this is what you need to do next. that becomes diagnostic and goes down fda pathway. the challenge is the balance with fda and whether these products just want to stay as a consumer product. yes? >> do you see anything coming out of this from all of your research and looking at this and the company evident where like

nonobvious things have become -- so an example, i was talking to a company a number of years ago. they saw people who filled out forms in pencils were higher credit risks. it was not something obvious or intuitive. are you seeing anything like that coming out of all this aggregation. >> interesting weight loss. there is a couple of research studies out now that are showing that weight loss has -- when people are wearing multiple different trackers, weight loss has more to do with the people you spend time versus your own food intake. so we're trying to identify, why are people eating when they are not hungry. that's really the basis of weight gain, you're eating when you're not really hungry. the correlation with that, with some of these sensors or input consumers are putting in is that the people they spend time with is really affecting their weight gain. so i thought that was an interesting one. from a physiologic perspective,

there are more and more studies coming out from our research with circadian rhythm showing changes in gene mentioned sir cad union rhythm, it the forgotten vital sign, because temperature really is making a big impact on a lot of these health care, not only treatments, but diagnoses. in the back? do we have time for one more? >> thank you. i think it's building off the gentleman's question some, and it is the soesicioeconomic fact for the individuals using the personal devices. those that likely could benefit the most can't afford them. so, how -- are you tracking any of that information? are you able to really say, you know, there's differences? >> well, that's where the companies that we're collaborating with and kaiser are choosing to -- our product specifically won't go down a typical reimbursement pathway since there's limited

reimbursement for fertility treatments, but etna and kaiser would like to offer our product at a deeply discounted rate for their members, because from an insurance perspective, now consumers are choosing their own insurance companies specifically based on what they can provide. so i think the insurance companies and the larger employers are starting to offer these at a deeply discounted rate. etna and apple just announced a collaboration for their wellness program a couple of days ago where all the etna employees will be receiving a free apple watch. so, that's a significant impact on allowing these folks to purchase a product -- or own a product that they could probably not purchase on their own. thank you. [ applause ] ♪ ♪ i went down to the crossroads, fell down on my knees ♪

♪ down to the crossroads, fell down on my knees ♪ ♪ ♪ all right, good morning. my name's christian garcia,

managing director for 776 ventures, a seed fund incubator here in washington, d.c. i'm joined by three health care executives ranging from the payor and provider side, and we're going to be talking about health care delivery system reform. maybe to kick things off, introductions here with you? >> sure. good morning. my name is will sneeden and i'm from aeon. aeon is the largest provider of health and benefits, consulting and administration services to employers in the united states. my role is i'm the national practice leader for our health and medicines consulting group in the u.s. so, i'm going to represent the employer view in the context of the health system transformation and the stake in the game that the employers have. >> good morning. my name is jesse turzon, chief consumer officer with novon health. you heard about that earlier with our president and ceo. i will tell you i am the least clinical person on this stage today because i have a background in banking. i spent 25 years in banking with

a company that was called ncnb, went to nations bank and now bank of america. that was a $1 billion business and we drove it to a $100 billion business, and i share that with you only to make one point, and that is that banking went through major transformation over the last 25, 30 years, and through that created better opportunities to access to 24/7 banking, created opportunities to better understand their segments through consumerism and segmentation. we'll talk a little bit about that. you've heard about consumer iis already this morning. but i will also tell you in my role as the consumer strategy executive is health care is likewise going through a lot of major transformations within the industry. look at novant health today. a patient can come to us and have very easy access into our offices through online meetings with the doctors. they can look at their

prescriptions. they can find out and make appointments through online activities. so, novant health is not only consumer-focused, but spent an awful lot of time looking at consumer research and using that consumer research to really inform how we're building our business. so, the perspective that i will share today is how we're looking at the consumer, how we're using that information to inform our strategy. >> david morales, the other nonclinical person on stage. chief strategy officer of seward health care system, an integrated care model in new england. i oversee many of our product development, medical malpractice, our reimbursements, and i'll talk a lot today about incentives and how we're driving delivery system reform in massachusetts. prior to my tenure at steward, roughly almost six years, i was commissioner of health care finance for massachusetts and led a lot of discussions toward cost containment and changing regulatory incentives for providers and payors. >> all right, thanks, guys.

and i'm a mechanical engineer, so this is a very nonclinical panel. the title is "panel delivery system reform," three words which could mean something different to a lot of people and a lot of organizations. so maybe just as a level set, what does that mean in each of your organizations? >> yeah, so, let me provide a little context leading into this. in 2016, employers sponsor health insurance plans that are going to run on average about $11,700 per employee in plan costs, and that's going to be shared with employees, about $9,000 cost per employee for the employers themselves and about $2,700 employees are paying on average in payroll deductions to buy the insurance coverage. and for those employees, not only are they paying the premiums payroll deduction, but they're also picking up out-of-pocket costs, another $2,300, on average. so, employees of these employers are spending about $5,000 apiece

on average for health care during the course of the year for themselves and for their families. so, it's significant cost. it continues to rise. and employers are constantly looking for ways to manage costs better and achieve better health outcomes for their members. and those employers, those companies, i think we find that companies want to and need to be bolder in the strategies and the programs that they want to employ to help manage costs and drive outcomes. and one of the shifts that we're seeing is on one hand continued commitment to the idea of well-being, physical, social, emotional and financial well-being. but at the same time, we're seeing a little bit of a change in emphasis around employer strategies to try to focus as much on the provider quality and costs, more so than they have in prior years. and i think that part of that's driven by the fact that there is transformation going along with the delivery system. the provider system's trying to

clinically integrate better. the movement, as we talked about earlier, from paying for volume to paying for value, i think it represents an opportunity for employer sponsors to look at all of the locations where they have significant membership and how do they take advantage of and maybe in some cases drive some of the transformation that's occurring in the system so they can deliver health insurance at low lower cost and with better health outcomes to their members. >> for novant health, as we look at a value care environment and strategy, first, it really starts with the consumer. how do we begin to define the consumer? and i ask you to follow along with me here. so, we have kind of a three-prong view of what the consumer looks like. for us, that first bucket is that nonpatient consumer. those are the individuals today that are not welcome into our queue facilities or clinics. 55% of the population that's not engaged whatsoever. and so, it begins with how do we begin to tell our story? how do we begin to communicate

with those consumers long before they need us and build in a strategy to connect with those individuals? that second bucket, which is really the more traditional bucket, is the patient-consumer bucket, and that's the bucket of patients that typically will go into their key facilities and the clinics. and what we have done in that bucket is to better understand both that patient population, but more importantly, we've identified six segments within that patient population. and within those six segments, some of them are highly, very engaged with our organization, some of them are unhealthy and not engaged with our organization. it goes across socioeconomics, it goes across gender, geographies. and from that information we're better informed in what we can do and how we can better engage our patient consumer. now, the last bucket of that consumer population is really something very interesting. we refer to them as a client patient. and so, kind of go with me here. you know my background is financial services. so, in financial services, a client was an individual that we

had a very in-depth relationship with. that was an individual that typically was an advocate for the organization. they refer customers to the organization, and you had a really deep relationship with that individual with very high delight scores. so, when you think about the continuum of the consumer, the nonpatient consumer, the patient consumer, and you think about this client patient, what would we then have to do on the front end of nonpatient consumers or the patient consumer bucket to get to that point that we are actually identifying client patients? what would a physician have to look like? how would a physician have to communicate in a very authentic way to a consumer, if that was ultimately the goal? when we surveyed our patients, our consumers, what we found are things that are not going to surprise many of you, but there were really three major themes. and the first one was all of our patients were very interested in access, and supreme couccess wa 24/7 access, by where your

clinics were located, by how you allow me to engage you, whether it's electronic engagement or some other form. we have over 600,000 of our patients that are actually on my chart, they're using electronic means to make appointments and to communicate, ultimately, with their physicians. 60 of those 600,000 are actually over 100 years old. so, the notion that people over 100 aren't using electronic engagement is false there. so, access was important, transparency was ultimately important, cost. how do you create cost certainty within the environment? and then thirdly, how do we ultimately leverage technology? so, when we think about payment reform, we think that as we move to a value-based care business, we're going to have to leverage access, we're going to have to leverage technology and transparency. and by doing that, we feel like we're going to be more effective in making our communities healthier. >> so, we started down the journey of delivery system

reform back in 2006 in massachusetts, and we started with three foundational pillars. the first one was cost containment. the second one was sustainable access. and the third one was quality. all those wrapped up into value, frankly. and so, i come from a system, at least in health care over the last six years, roughly, where we took the pillars of value, the highest quality care in the most efficient manner, and burned down an inefficient system. we said, look, we're going to fully integrate the system, hospitals, emergency rooms, home care, ambulances, physicians, mps, et cetera. we're going to put the entire system at full, downside financial risk on the commercial side, and we're going to try to now integrate all those services in a way that drives value for our patients and for our providers. so, what did that lead to? for us, it led to two fundamental things that i define as delivery system reform.

for providers, it led to aligned incentives for better care delivery at the patient point of care, right? our physicians, our nps, pas, all of our assistants, our providers, should be incented to drive the best care possible, almost kind of like what carl talked about earlier, right? we should all be driving toward the best care possible as soon as the patient engages you, wherever they engage, whether it's on the cell phone, whether it's at the urgent care center, et cetera. candidly, the service stream did not allow for that, so our commercial side allows us to essentially create those incentive a's for providers. on the patient side, which is the second foundational concept we should talk about, it's a little bit different. you've got at the provider point of care, you want to be payer agnostic, but on the regulatory and reimbursement side, you've got to recognize that there are three very fundamental sets of consumers. there's a commercially insured, which probably most of us are.

lots of different incentives and things we can do to actually engage patients in their care. medica medicare, it's a little more challenging. there are very, very strict rules around which we have to operate carefully to try to engage those patients. the medicare aco models are helping us get there with some waivers to actually directly engage patients, but not as easy, and frankly, the incentives are not a lot for patients or providers to move toward that full spectrum of value. and then there's medicaid. demand medicaid, right now we're launching within the state of massachusetts a medicaid aco that's hopefully going to allow us to engage that patient population in a very different way. that population doesn't have cost incentives, doesn't have co-pays or deductibles. and so, their consumption of care is very different. their incentives are nonexistent. so, we're going to try a new set of engagement tools starting december of this year to engage that population in a very different way of care.

>> so, a couple things i heard, common themes both early this morning and from you guys is just this notion of patient engagement, right? and i can tell you from the investment side, from the venture side, there is a great deal of emphasis and excitement on how you drive quality and outcomes through engagement. but frankly, you know, people are experimenting with different things, a lot of stuff doesn't work. so, what have you guys seen in terms of innovations or technologies that are really driving quality and outcomes through engagement and what has been working or what have you seen on that end? >> look, i think technology's really important, but there's two sides of it. on the provider side there's no silver bullet. there are many engagement tools that we're using on the provider side to help them, "a," educate them about their care practices, the variation in terms of practice delivery that we have across many of our physician offices and across the hospitals. and so, electronic medical records, ehr, whether you're

talking about e-clinical works or patient ping, which is one of the most recent we've implemented as of about 12 months ago. it's helped our providers identify patients, where they're accessing their care, how to practically engage them quickly, depending on where they're getting their care. that's been helpful, but has it reached what i call maximum efficiency? i don't think so. i don't think we've reached a silver bullet yet. on the patient side, in the commercial area, for our commercially insured products, we've been able to deploy a lot of those technologies, and under risk reimbursements, downside risk, we've been able to actually pay for those. for medicare, for medicaid, there's no revenue stream for us to explore those types of solutions, so there's variation in terms of how we're dealing with our patients on that side of the house. now, in terms of the point of service, we treat everybody the same. but how we actually pay for those investments, that's where there's variation. tools, so far, technology, we've seen some results. patient ping's one of them that's actually been working really well for us, but i'm assuming that in the next three

to five years, we're going to be talking about the golden age of technology and how we're actually helping to directly engage patients in their care. >> so, novant health we think is a shared engagement. we think the best-informed patient is one that's engaged with our system, but we have a responsibility as well. so, when we look at the new paradigm, and clearly, we think that the new paradigm is going to be driven by consumers, we think it's our responsibility to take the time and invest in research to better understand our population. i shared with you the research that we have done that's led us to understanding the segments. you know, the better we understand the behaviors and needs of our patients, the better we can ultimately engage them. most recently, a consumer attitude study that we did that really focused on a broad population but also focused on millennials shared with us some very insightful information. clearly, millenials use their phones an awful lot, and you would expect that to be the case. you would also expect that most of the information that they

would get, they would get it from the internet. but what we found, that when it actually came down to how they prefer to get their actual information from physicians and clinicians, they've really gone old-school, because they want to actually talk to a doctor, they actually want to talk to a physician. our ceo spoke earlier, and he really talked about as we looked at that population as well, what we know to be true is that they value respect equally as much as they value medical treatment. so, what that means to us is we have to really develop strong relationships with our patient populations, but more than anything else, we really have to know who they are. we have to know how they prefer for us to interact with them. we found that some of our consumer patients actually did not have a preference on whether it was a primary care physician or whether it was some other type of clinician within a clinic office. and so, we found that some of our patient population prefers for us to interact with them through technology. so, when it comes to engagement,

for us, it's really about understanding who the consumer is, understanding what their preferences are, and based on that, we feel like we have the best engagement, which ultimately results to better quality health care. >> quick question. can i just peel back the question, right? >> yeah. >> technology's important, but i think even more important is, what's our objective? if our objective is to try to drive better care management solutions in the context of a cost containment/high-quality performance objective, then i think it makes sense for us to explore the right tools that are going to help us to achieve that, depending on the segment of the population. let me explain. under a medicare aco model, we were able to identify that about 10% of our population or our users -- we had roughly 100,000 lives under risk -- about 10% of the population was literally 80% of our expense, and they're mostly nursing homes. so, we were able to ploy

technologies, like patient ping, but also care navigators in the nursing homes and by proactively reaching their homes, phone calls, et cetera, to mitigate the e.d. and the s.n.i.f. efficiently. huge savings and better outcomes in the quality scores. for the commercial insured patients, our objective was a little different. a lot of these folks would get going to wherever they chose for their care, which is great, that's a good thing, but you want to do it in a way that's in concert with your primary care physician or your care protocols that your primary care doctor's trying to sort of work with you on. and so, that took a whole different set of strategies on the technology side to try to get patients adhering to the care protocols that they were talking to their doctors about. so, i guess as you step back and say, look, let's talk about technology in the context of what makes sense, because under a cost containment agenda, it's not about a revenue model, it's about a cost model and how to actually get to the right outcomes using the right set of

techniques and technology. >> so, david, obviously, i'm thinking more of the context from the cost model than the revenue model. >> absolutely. >> thinking about the expenses for health insurers. from the standpoint of engagement, i agree 100%, jesse, your comments about it's about the consumer experience, right, that's going to drive engagement. people have a good experience, they're going to go back and participate and engage in whatever it is that you want them to do. and from an employer standpoint, there's probably three main areas to focus on from an engagement. one, the decision points, how they select their health insurance programs in the first place and how you give them decision support tools so they know the doctors they want to see or the prescription medications they need to take are going to be covered at the highest level in the plans that they're selecting and what's the best trade-off of costs for between payroll deduction and out-of-pocket costs. two, when they're actually in the system, how do they remain healthy? how do they not need to receive care? and a lot of the technologies that we talked about earlier, the activity monitors and

everything, we're kind of a metrics-driven society. people like to know where they stand. and so, just some awareness of health and health behaviors is really important. i think they do serve some positive purpose just by getting people aware of their health behaviors, whereas in the past i don't think they thought about it as much. their sleeping and eating and activity are so, so important. and third, when they actually need to seek care, what do i do. so, in that case, i believe in a little bit of going old-school. so, a lot of the technology helping to access and compare providers and alternative treatment choices, that's great, but in the end, a lot of patients, they're not making decisions truly based on cost. and they have a hard time understanding and believing the quality metrics. having some assistance navigating the system's really, really important. so, i actually believe that whether it's, you know, an employer's responsibility or the health systems or the carriers, the members, the patients, they

need more navigation to help them through the system, especially the most complex care, which is where 80% of the costs are going to come from in the first place. navigating and getting some almost hand-holding advice to understand where to go and how to pull together all the information to receive the best care, and their own personal care, is really, really important from an engagement standpoint. >> let me just make one point about my teammate's point really around technology. let me be clear about something. in health care, the best technology is going to be an assumed fact in this industry. and so, we've spent $700 million on electronic health records at novant health. and let me tell you what's the new paradigm. the new paradigm is you're going to have to stratify patients. you're going to have to stratify patients when it comes to those who have the high propensity for chronic disease, those that are healthy, those that are not. you're going to have to stratify patients from a risk standpoint on the payor side. that's going to be standard in health care. you'll have to be able to do

that to be competitive in the business. what differentiates health care systems and what the consumer will tell you, it's about how you make me feel. so, it still gets back to that authentic relationship, if you're going to retain patients, if you're going to grow patients, if you're going to really create a remarkable patient experience, it's really going to be around that authentic relationship that you create. and we will not be able to do that until we begin to look at patient consumers differently, just as other industries. other industries segment extremely well. they understand that every patient that they connect with have different attitudes, different beliefs, different wants, how they want us to interact with them. and so, health care, you know, when you think about the triple aim, when you think about experience, when you think about cost, when you think about all of those things that are ultimately important, quality, those things are going to be essential. but for us to grow, retain, create stickiness, it's going to come from the heart. it's going to have to be authentic. >> let me jump in real quick. you mentioned electronic medical records. we've heard it a few different

times from different speakers. i just want to toss out one point, and that is that we need a better way for electronic medical records to be the possession of the member. i think that the provider systems and electronic medical records the way they're set up today, we need a better way for that to be portable and for that information to stay with the patient over a longer period of time, you know. i've had services done myself, sought care. i should have the records of that care to take with me so i can see other providers or if i move to another state, it's easier for that to come with me. and i do think that's something we'll see in the next five, ten years where it becomes more standard that an individual has their historic medical information with them as they move around. >> yes. so, i want to touch on -- so, you mentioned first how you navigate the system and how the patient, how you make the patient feel. i can tell you that, you know, again, one of the reasons why it's exciting to be investing in this space is, frankly, because the health care experience is really bad, right? so, there's a lot of opportunity there. and earlier today we've been talking about the

consumerization of health and there's so many things in our everyday lives that are getting easier, right? like going from point "a" to point "b" is easier, finding something online is easier. everything seems to be getting easier, and yet, the health care experience in many ways does not, right? so, kind of pulling on the thread of who owns that patient experience, who owns that experience of how to help the consumer navigate through that. usually when i look for a doctor, the first place i go is my insurer, right? and thso, that's kind of the entryway into my experience, but then you kind of get lost there. maybe you can walk through that a little bit. how do you think about that? >> yeah. so you know, that's a hard one, because no offense to the health plan representatives in the room, but health insurance carriers have a very low, you know, consumer rating from members. they're concerned about whose best interests they're serving. the provide systems, more and more we're seeing members that they're not just simply assuming that the doctor's word is gospel, and they're willing to

debate and discuss whether or not the providers are acting in ways that are in the patient's best interests. i guess it's the hip democratic oath, but i think there's some question about that right now. so, where is that most objective, unbiased opinion going to come from? i'm not sure there's a great answer to that but that's one of the problems. you have a system where the dollars flow in a very different way than the consumer decision is made. so, i think the consumer naturally have -- and i almost hate using that term, the patient, the member, the consumer, the person really needs that sort of unbiased help to know they've got someone thinking fairly about their personal interests. that said, the systems themselves, we have such a complex health care system. and you guys have to send patients to lots of different places in order to complete an episode of care, right? and it is natural that the health system itself needs to help direct where the patient needs to go and what order they need to go. so, i think once they're in the system, the navigation probably starts at the provider. let's face it, health care

happens where the patient and provider come together, and that's probably the starting point. >> i'm a big believer in incentives, so i'm going to say probably a few controversial things. the first thing is we have not incentivized the entire provider or payor industry to move to value. we are still in massive mix mode of reimbursement. there's fee for service, there's bundle payments, there's accountable care organizations, there's shared savings, there's downside risk, et cetera. and so, you have over 32 payment models that medicare is now exploring. you have the commercial, which have over 150 across the nation. we're still in a very mix, but underlying all that, 80% fee for service. and until we move to a paradigm which pushes all of us toward the right place, i.e., value, good quality, low cost, we're going to continue to have this conversation. part one. part two is, when you look at how the patient is going into the health care delivery system on the commercial side, you're

right, we go to the health plan and say what is my insurance benefit? often, the plan design is not truly aligned with a high-value outcome that you're seeking. what do i mean by that? in boston, where we have some of the world's best academic medical centers, the quality that those academic medical centers deliver, at least on paper, according to medicare, is the same as a community hospital 25 miles down the street. but the perception of the quality is that boston is better. guess what, they get reimbursed 70% higher than the community hospital, which drives your premium higher. you as a consumer don't know that. and so, you're going to say i'm going to go there because it's better, but you're not really making a value-driven decision. so, that's second issue two. how do we move the regulatory and plan design environment so that patients understand that exchange of economics. the third part is directly on us as providers and payors. we've got to silo, and maybe the right word's not desilo, the right word's probably socialize data. data today is a competitive

advantage. let's all be candid with each other. until we socialize data, ehrs, emrs, reimbursement, price, quality outcomes in a very public way that we together can work through that as a public value, that's another challenge that i'm not sure we're going to be able to bridge to get to the world of consumer engagement in a more meaningful way. >> first of all, let me say, i think it's a very complex question. to some degree, i responded to it earlier. on the surface, i will tell you that it is shared. it's about patient engagement. it's about what we are doing to better understand our consumer so that they're receptive to navigating our system. it's using technology, it's providing access in a more broad definition from an access standpoint. in addition to that, however, it has been revolutionary. it is how can we create those operational models that best

suit the needs of the consumers? one of the things that we're working on and really speaks to the payment side is our strategy around bundles, whether it's the medicare bbci bundle strategy, where you're really in essence creating transaction or procedure certainty as well as cost certainty. and so, we see that as just another pathway of better engaging the patient population. because in essence, what we're doing is we're create a bundle to say here's what it will cost you. we're creating partnerships within the system with providers and clinicians to say this is what this process will look like, whether it's knee replacement, whether it's pneumonia, whether it's congestive heart failure. but more important than that, it's the experience postacute. it's that 90 days, what happens? who are the skilled nursing facilities we should go to? who are the home care facilities that we should go to? so, as we begin to get on that path, we're not 100% downside risk, but we're moving in a direction that we know that we're going to be in an environment that we're going to have to manage risk.

so, these are some of the things that we're doing today because we know cost certainty and procedure certainty are ultimately important. because we started down this path, we have over 40 skilled nursing facilities across our system that are working together today. we have over 40 home care systems that are working together today. so, in a more complex way, that's how you begin as well to talk about engagement. who owns that? we own that because we want it to be easier for our patients, we want it to be a remarkable patient experience. and so, that's just part of that very complex model of really moving in a very gradual way from a fee-for-service industry to a value-based industry. >> that clinical integration is so important. and you talk about bundling, bundling payments. the consumer or the patient, they actually think in bundles. i have to have a knee replacement, i have to have a hip replacement. they don't think in terms of codes. that's the mind-set. so, you're actually meeting the consumer where they're coming at it from. >> but i'm going to push back on that, right? because we should be thinking

about population health, right? we shouldn't be thinking about a bundle episode or an episode of care. our job, i believe as clinicians or providers or thinkers for our system, is treat a community, treat a population, right? and so, if we're thinking in that direction, then we've got to be tying together both the outcomes, the community health, the social determinants of health as part of an overall strategy for our patient. and so, when we think about an episode of care, let's say a knee replacement, that's not truly enterprising or looking at the person's overall health, and that's part of what i talk about incentive, right? if we're going to incentivize our clinicians or providers to think about a patient, a bundle might not be the right strategy. it might be what's happening in your home? let's look at the medicare patient's home, let's take a look at the type of social supports they have around them. maybe they're using the emergency department because that's where they go for their social space. and so, we've got to think about a person's overall health as we try to engage the discussion on

value and incentives for patients. >> i would probably disagree with that, because i think bundle, in essence, is population health. so, when you think about population health, if you think about the triple aim, if you think about experience, certainty, if you think about costs, the baseline to doing bundles is to reduce overall costs. and so, think about costs, think about the experiences, think about quality. and so, the baseline model of creating bundles, particularly if you look at medicare, it's all about readmissions. it's all about making sure that patient's not coming back into the system. so, i do agree that population health is much broader, and you can get into stratifying patients and looking at populations and leveraging registries within a population, but the bundle strategy is an element of population health. and if you do it effectively -- you know, i agree, i think bundles are our future. think about other industries.

bundles are our future, and the reason you do that is because of price certainty, quality, is because of outcomes. so, i disagree, but -- >> full disclosure, i'm an actuary and between the two of you, on average, you're both right, so. just kidding. >> just in the interest of time, i want to move forward to kind of predictions, right? and i'll give you a little anecdote. i was talking to a company that's trying to be the uber for ambulatory care, right? you pick up your iphone, order a guy with i don't know what training he's got, but it takes you to maybe not mixed an entry, but to the doctor of the hospital. on the surface, you're thinking that's crazy, nobody would do that. and there are so many things we do today that not long ago seemed crazy, right? so, i want to throw it to you guys in kind of the five or ten-year time horizon of crazy predictions, what do you see in terms of ways that health care will be delivered or just delivery system innovations generally that again right now might not be something that we

would think work? >> so, let me just start off with that. i will tell you, i thought we saw a great presentation earlier around wearables. and i will tell you, i think that's a big part of the future of health care that people will have realtime monitoring, realtime data that physicians can monitor and look at, and ultimately, can anticipate and prediction. population health is all about predicting and keeping communities healthier. i think that you'll see a shift from the type of hospitals that you see in communities today. i've used the term that in the future we may not call hospitals hospitals. they may be institutions of wellness. we'll move from the large hospitals of today to the smaller hospitals that are far more accessible and far more consumer-friendly, and they will focus on probably 80% of the relevant conditions that are needed to be met within those communities. it will look different, it will feel different. they may have wellness facilities, exercise facilities as part of the facilities

themselves to encourage people to, again, engage long before they ever need them. i think medical education will look different in the future. we talked a little bit about what we're hearing from our consumer populations, and we clearly know that they want to be respected. so, i think how we train our doctors in the future up-to-the-minutely are going to be different. we're going to be looking for people who can deal authentic relationships. we're going to be looking for people that know it's not about the doctor will see you now, but it is the consumer patient will see you now. i think education will be different from a end-of-life standpoint. what i found interesting leading a wealth management business for bank of america is one of the things we were really good at was, from a 30-year standpoint it was around how do you accumulate your wealth, how do you retain your wealth, and how do you transfer your wealth? that's estate planning. that's estate maturity. that's death. there was a lot of deliberate discussion around what happens at death. we do not do that well in health care. so, i think that from an

education standpoint, we'll put more emphasis on how do we empower our consumers. empowering our consumers is giving them an opportunity to have a choice, to make a decision, to select family members to help them with those very difficult decisions. it's not just health care. it's this country in general. and that's an opportunity for s us. i think in the future medical schools will do a better job helping individuals talk about death and moving on. lastly, this is the challenge, i would say to all of you. we have a real opportunity. the millennial group that 18 to 35 to 36-year-old group, we have an opportunity to educate them about wellness today, to use wearables and other kinds of means of connectivity that we can take an entire generation and make them healthier. we can eliminate or minimize diabetes. we can impact high blood pressure. we can impact obesity. >> look, i guess i'm looking forward, looking ahead.

i hope we get to a place where people in the united states, wherever they live, can access high-quality care, wherever, regardless of where they live and regardless of whether they have medicare or medicaid or commercial insurance. i'm looking forward to a time where people actually have proactive health planning that happens between your care planner, your care navigator, your primary care physician, your specialist and your health coach. i'm looking forward to a time where actually providers are paid for those things, rather than what we're doing today. i'm looking forward to a time where providers, community health centers, ymcas and employers meet together to think about their employees' wellness so they can be more productive at work. and by the way, we're paid for that, right, to plan ahead. i'm looking forward to that time. i think we're far from there, but i do think that in terms of the move to value and contracts on alternative payments are helping us to learn how to actually get to that place, and

i hope it's not in the far-too-distant future. >> i know we're running short on time. you asked an actuary for crazy predictions and i'll probably start talking about trend rates. steve jobs said we always overestimate the amount of change that happens over the next 12 months and overestimate what happens in the next ten years. a year from now looking out, things may not feel that much different. we'll feel gradual shifts in direction, but i think over the next ten years, the whole entire delivery system is going to be a lot different than it is today. telehealth, the use of data, mobile technology will have a huge impact. from an employer standpoint, it will be kind of a different approach, i think. employers are, you know, grasping at the concept that health care is local. it's going to move at a different pace and a different form in each geography where they have members. health care is personal. we're dealing with five generations in the workforce. we're dealing with differences between, you know, income and background, race, gender,

ethnicity, personality, et cetera. and health care, ultimately good health is good for business. help your employees be more engagend more productive. more productive ploiz employees generate better business results. it's a very linear equation. it's hard to prove with a mathematical algorithm, but i think employers are going to adopt that mind-set and really focus on how to maximize the health of the population, and hopefully, through the delivery system, we're going to bring in the cost control and the higher quality services we're looking forward to. >> i'll just end with this note. and i agree with you, i had a boss who had a quoete on his office he thought was important for venture, a hemingway quote that says "all things happen in the same way, gradually and suddenly." so, i think that's probably true. thank you all, gentlemen, for joining us, and i think that's it for this panel. thank you. [ applause ] ♪

hello, everybody. very nice to meet you and thanks for coming and thanks for trying to listen to a little bit of different presentation than what you heard today. i am going to talk about internet of things. of course, a little bit of health care, but it will be more about internet of things and

iot. i work as an associate director of cyber fiscal systems at nist. nist is part of the department of commerce, and we work mostly on science and engineering. so, a little bit of stats. nist is a d.o.c. bureau, and we have about 3,000 scientists, engineers, and also close to 2,800 associations and facility users. we had about five nobel prize winners the last 20 years. so, you can kind of see that we've really focused on science and engineering. so, why are we talking about internet of things? and we heard about wearables today. and wearables is a part of iot

in general, but it is a bigger picture of cyber physical systems. by the way, cyber-physical systems has not been more than iot, internet of things. cyber means connectivity, internet. and physical means things that you can, you know, touch, feel and so. so, cyber-physical systems is iot. what it really means is a hybrid system of physical components and connectivity and software. virtually everything you see these days kind of falls into this category, smart thermostats, smart vehicles, smart health care, smart sensors, anything with the word smart, that means you have something with a cyber component on it. by the way, please do not confuse the cybersecurity. that's not cyber-physical systems. when we talk about cybersecurity, that's a whole different world, and i'm not going to talk about cybersecurity today.

so, why are we talking about iot and cyber-physical systems, which is cps? 200, 300 years ago, industrial revolution changed our world. essentially, what it did was they came up with a new way to manufacture the goods and the products. and then 50 years ago, 40, 50 years ago, this internet revolution has completely changed our lives again. what did it do? it changed our way of doing things using internet or pc, if you will. for example, we didn't have to keep our log books anymore. you have an xcel spreadsheet which does a beautiful job, and you have financial software that can take care of our tax return, for example. so, if you combine this industrial revolution with the internet revolution, that ends up with the cyber-physical

systems. now we combine the physical revolution with the cyber revolution, that becomes the next wave or revolution. so, by the way, i can't believe it's going to be 80 degrees here in mid-october in d.c. i'm from boston. it never happens over there, okay? so, i was brought in -- i came into d.c. about three years ago, okay? i was brought in to work on iot. they gave me -- they hired me as a presentation fellow to work on cyber-physical systems. and three years ago was about the time that all this buzz around iot started to come up. by the way, iot's not new, okay? it's been around for probably decades, more than two, three decades. it was called m to m at some

point, it was called smart systems, it was called all these different names, wireless networks and so on. so, why are we hearing all this buzz about internet of things? so, really it comes down to the cost issue, the sensors which you had to pay 100 bucks to get a decent sensor to measuring temperature. now you can -- i'm not talking about the whole product, i'm talking about just sensor -- now you're connected by a couple bucks, which is extremely, extremely impressive. and also you can kind of see the sensors and collective data, a model of sensor and data that increases exponentially and creates a new opportunity for us. so, let me go through what iot is.

the bottom layer is the hardware layer. these are the physical components, sensors, actuators and radios and chips that you can touch. sometimes this is as large as a car or an airplane sometimes. on top of that, you have a communication layer. essentially, you connect these things through wi-fi, cellular network or a bluetooth, whatever you can think of as a connectivity. now, a lot of people think that iot is the bottom layer. that's wrong. there are two more extremely important layers that really adds value, both from commercial perspective, also from the research perspective on top of that. so, on top of the communication layer, there is this data analytics layer. this is where you take the data collected from bottom layers and

extract useful information. so, by the way, there was one thing i agreed with one of the speakers that spoke an hour ago. data, a lot of people say data is the new currency. it is extremely valuable. i do not agree. data has almost zero value. data is basically 1s and 0s, there's no meaning. if you have a bunch of 1s and 0s, it doesn't really mean anything. that doesn't really have a lot of value. the value is created when you extract actionable, useful information out of this set of the data. that's where data analytics comes in. that's where the real value and business value is created, okay? atop of that, there is a service layer. this is the most important and the most valuable layer. this layer makes a decision based on the information collect tlih all these sensors, wearables and all these things.

you have to make a decision on what to do with it. it's not just a visualization. you have to take an action. when you take an action, that's where the 90% of the value of iot "e" system is realized. if you look at the information flow, it's not just the monitoring, actually, it is also taking action, meaning that you are coming back, closing the loop. i'll give you one example. about 16, 17 years ago, at m.i.t., they developed something called a ring sensor. this is a great idea. it's a finger ring, essentially. you have batteries, you have a cp, you have a wireless, optical sensors. essentially it detects vital signs, you know, heart rate and oxygen and blood pressure in a finger ring, and you carry it 24 hours. wherever you go, if there seems to be a problem, then you get alerted.

so, that was back in 2000. great job, right? so, you may ask the question, that's a great idea. i want to give it to my fiancee for my engagement ring. why can't i buy it from tiffany, right? yeah, there is a technology issue, technical issue. it is extremely tough to put everything into this small ring and then actually you go, you know -- first, first, most, the customers who will use this ring is essentially either patients or, you know, people who needs monitoring. so, they are not going to be used to changing battery, replacing battery every day. once you have this in here, it has to go for months or years. that's challenging, right? but in addition to that, the issue is much bigger than that. so, when i was brought in as a

fellow, i was given a task to figure out why we are not seeing -- why we are not seeing exponential growth of iot and cps in our world, okay? we see incremental growth. we talk about it. there are a lot of wearables coming out on that, but we do not see the critical momentum like cell phone industry enjoyed for the last 20 years, okay? so, why is that? what he concluded at the time was, it is because of iot and cps landscape's extremely fragmented. give an example. medical devices companies develop madical devices, but a lot of the technology they are using could or can come from transportation system or personal, you know, smartphones, for example, or from disaster response system, okay? they're all developing these things in silos.

they do not have a lot of interoperability, they do not share a lot of the knowledge, experiences. so, how do wome encourage collaboration and tavlgible benefits and technologies of scale? that's really the core question. i'll give an example what it means by cross-sectorial collaboration or cross-sectorial example. crash-to-care scenario. you have a huge accident, pile, in a highway. and what happens? somebody's going to call 911 and ambulances are going to come. they're going to start calling hospitals around, and who has the beds available, who has the right surgeon and doctors available. if they are not available, you've got to call another hospital because you have 30 injured people. it's a mess, all right? in this example, what you do

today is literally use your cell phone and call hospital. that's what you said, command center. this was an example in the boston marathon incident a few years ago, and they did a great job to take care of the situation with a given limitations in systems. but we believe we could have done better if you had a system that could coordinate and orchestrate and also connect these different emergency response system -- hospital, triage system, availability of the hospital resources and availability of the traffic. ambulances, obviously, they all want to come in there faster. can traffic system handle these kinds of situations? if you had something like this, cross-sectorial collaboration, that we could have done better. so, a few years ago, we created

a program called the smart america challenge, a collaboration program to bring in industry, academia, agencies all together to really encourage a collaboration with a very specific goal, like saving lives, creating more jobs, creating more businesses, and improving the economy. that was a very successful program. and after that, nist basically took it, what we call institutionalize. i'm still trying to figure out the terms. i'm not exactly used to that. i'm trying. institutionalize it and create a program called a global city teams challenge. and the goal is pretty simple. we want to create economies of scale. whatever we do in iot, health care, disaster and transportation and environment. because without economies of

scale, it will be just science fair going forward. it's going to be just the bits and pieces here and there. we want to create rep kabul, sustainable and scaleable model, and we want to bring in cities, why? because cities is a unit that you experience your life every day with, all right? so, with a partnership with the cities, transportation, health care, environment, we wanted to create teams and create a measurable impact. so, currently, we have about 100 teams in total, over 120 cities from all around the world participating, over 300 companies, universities, non-profits are participating. so, what do we do, okay? so, this is what it do. this is actually a smart city capacity-building program, but health care is an extremely important part of it. if you go to any city and if you go to the health care department or the environmental department,

they work with the companies, obviously, and they work with the hospitals. but those are extremely fragmented, and they come with their plans one by one. essentially, the plan in new york city is not designed to work with a plan in boston or san francisco. the problem is, if every city has a different plan and different homegrown solutions, you're going to never get to the economy of scale. cities are not happy because they have to reinvent the wheel over and over again. companies are not happy because they cannot sell their products more than once, right? it has to be customized all the time. whether it's a database, data analytics system. and that is a big problem. so, how do we address this issue? we address this issue through a concept of action clusters. so, instead of each city working with each company or university, we want to bring in multiple cities, get them around, coalesce them around the same

topic of the shared interest. transportation, autonomous vehicles, health care, air quality, asthma issues, and also, we want to bring in companies and universities to coalesce around the topics. so, outcome of this effort will, naturally, because it was developed by multiple cities and multiple companies, will be replicable and sustainable. we have done this over the last year and have over 100 action clusters we have put together. now, next step, we want to go with the super clusters. what does that mean? so, i'll go to more of a health care example here because this is a health care conference, but it's related to other sectors as well. every sector -- transportation, water and health care -- has specific solutions they develop, but each solution by itself cannot create the real synergy. we need to bring them together

under one umbrella. so, that's what we're doing. multiple action clusters get together, create a supercluster and create a blueprint, implementation plan that can apply to any city in the world. i'll give a few examples of what happened during the last three years out of this over 150 teams. closeloop health care -- that's a mass general hospital collaborating with a bunch of companies and universities as well. essentially, this is an example that was also addressed in previous presentation. there is a data set that you collect in your home. i mean, you have a home secure system. when you have a heart attack, you are brought into the hospital in ambulances and the hospital goes through all of these tests again. i mean, they put you through ekg and all kinds of tests again.

if you had an access to the data set that you already collected for the last three years at home, wouldn't it be great that you can figure things out a lot easier than you have to go through all these tests from the beginning water more time? so, that's the concept. how do of how do you try to coordinate -- the home health care system to different hospital health care system? bottom left, this is emergency life support. this is about the crash to care scenario i talked about. there's detection sensors into a senior living facility. by the way, you probably know this, hundreds of people die every year in the united states because they just fall on the ground. not because they are sick, they just fall on the ground and cannot get up. they don't have mull ascle and strength to get up.

and simple detection sensors can solve the problem. if you can detect it, send an emergency department so they can check that out. i have a little time left so maybe i came too far here. so we cannot do this by myself. we do it with partnerships, with all these departments. national science foundation, ita, gsa, state and transitional departments work together also all the company. also this is international and global activity. one thing i can say is the u.s. cannot do it by its and it's not right that we do it by ours because whatever we come up with may not work in europe, may not work in asia.

then there's no economies of scale so we have to do it globally. so we go through this process and the way we do match making is by bringing them to an event. as one of the mechanisms next week, tuesday and wednesday, we are going to have a challenge to kick off a super cluster conference. so if any of you are interested in health care, we are going to have a separate health care session on it, please come and join. that's it, i have 15 seconds to answer one question. [ laughter ] can i get that one question? any questions. so either i was perfect or this was not exciting at all. thank you very much. [ applause ]

♪ note? ♪ ♪ note? >> we can cut the tunes, that music kills me. it doesn't look like me at all but i'm randy johnson at the u.s. chamber of conference and i'm just a like so i won't add to the people that provided by to me today. i'm particularly proud of our summit my goal is if we can bring together smart people and talk about technological advances, et cetera, and move the ball forward a little bit on disease treatment, on wellness program, we can call it a day and go home and i think we've earned our members' dues. on a personal basis, i've lost a sister -- two sisters and a

brother to cancer recently. both under 70. i also had prostate cancer several years ago and i picked up a tidbit in one of these meetings that gave me the information to reject what doctors recommended to me that i think were terrible recommendations and stuart steered me in a different direction for the proper treatment i got so the kind of things you can pick up here are i think useful but, again, if we can sort of -- i was listening to joe biden on npr and what happened to the cancer moon shot? he mentions it's moving ahead but we still have information in silos and i'm thinking ten years ago we were talking about information being clustered in silos and haven't we moved beyond that by now when we talk about health information technology, et cetera? so it's frustrating when these issues keep getting repeated but all we can do is hope we can move forward and keep hammering

away on it. i would be remiss not to mention that this afternoon we have another event. i hope you'll stay around. we're not buying lunch in between. sorry, there are goode delis around the corner. it starts at 1:30, the affordable care act and the future of health reform, looking back and looking forward. it's a way of saying what the heck is going on with the aca anyways? because you can read different headlines on how well the act is going. if we can establish that, maybe we can talk about solutions and as we go into this next year regardless of who wins the white house that's important. i do want to mention jennifer lin for her help on this and hillary crow with the foundation. we've partnered with the foundation on this with my develop, the labor, immigration and employee benefits division. i think they're great events and, again, thank you for all your work. [ applause ] so i did mention the law and i

think we're going to form a company and use our app in china as they goetz around the one child law over there. but we'll get a little kickback on that. so thank you for coming. hopefully you can stay around for the afternoon. it will be a great event. a little different twist, a little more policy, a little more politics but you'll find it very, very interesting. thank you for coming. [ applause ] also live today here on c-span 3, george mason university hosts a discussion on voter anger and its impact on

the presidential election and political process. that's at 4:00 p.m. eastern again here on c-span 3. the italian prime minister, matteo renzi, is in washington for an official state visit. we have coverage throughout today, including a welcoming ceremo ceremony, a joint news conference and the state dinner tonight. this evening at 6:30 on eastern on c-span, we'll see the north portico arrivals, the grand staircase official photo and the dinner toast offered by president obama and prime minister renzi. here's more about the state visit. >> describe michelle obama's style. >> her state dinner style? >> yeah, her state dinner style and apply that to the state dinners in general. >> well, i think when mrs. obama dresses for these grand state

occasions, the thing that really distinguishes her sensibility from the -- that of first ladies who've come before her is that i feel like it's much more rooted into a very contemporary hollywood idea of what is glamorous. and by that i mean, you know, she's not wearing anything that's particularly revealing or high slits or anything like that, but there is a certain kind of modern edge to it that really taps into what we're used to seeing coming down a red carpet. it's less regal and more glamorous. >> has it changed over the past eight years? her approach to these state dinners? >> well, i think her look has gotten to be -- in some ways a little more relaxed, if that makes sense, sort of within that framework of glamour. i think back to the first state dinner which was for india, the dress was gorgeous and her hair was up and she had the

bracelets, the whole shebang and she looked wonderful but then i think to some of the later dinners when she wore a dress by karolina herrera. and even though it was still quite a grand dress, there was a -- i think an informality to it. it felt more like glamorous sportswear as opposed to a full sort of head-to-toe look. >> what do you think the impact has been of her choices for these state dinners on the role of first lady but also on -- some have called them diplomatic art, on diplomacy. >> well, you know, i this i the first thing is we all want to be proud of the people who are in the white house and in that way we want to be proud of their hospitality, we want to -- we want them to put their best f

forward so very simply she's presented herself in a way that i think makes most people feel like, yeah, we can stand up on the world stage alongside of folks from france and italy where, you know, the notion of fashion is really something that's embedded into their culture, the other part of it is that these are really momentous moments that, you know, the photographs are going to go into the history books and for any design house that is enormous, it not only puts them into the publicer have knack lar n a way that red carpets don't but it also puts them in the history books so it lends a certain, i think, gravity to what they do. it lends a certain gravity to the idea that the american fashion industry is just as important of an industry as the food, the auto industry, all the things -- other