what to do with that data and then how do i, 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. you can 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 of this? >> 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 with 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 that patients are putting in or 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 expression based on circadian rhythm. chemotherapy and other treatments. temperature we call it the forgotten vital sign. temperature is making a big impacts on a lot of health care not only treatments but diagnoses. do we have time for one more? >> thank you. i think it's building off the gentleman's question some, and it is the socioeconomic factors 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 aetna and kooizer 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 aetna 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 1776 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 sneden 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 cureton, chief consumer officer with novant 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 transformation created opportunities of better access 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 consumerism 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 steward 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 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 bracket 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 healthy, 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, access was defined by

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 a bankrupt system. we said, look, we're going to fully integrate the system, hospitals, emergency rooms, home care, ambulances, physicians, nps, 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 incentives for our 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. 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. in medicaid, right now, we're launching within the state of massachusetts, a medicate 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.

we were able to implement a couple different technologies, 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. inappropriately. huge and massive savings, and by the way, better care outcomes and 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 so, 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 hippocratic 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 payer 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 maybe it's not emergency ambulatory, but he takes you to the doctor or 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 predict. 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 ultimately 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 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 engaged and more productive. more productive 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 quote 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 excel spreadsheet, which does a beautiful job, and then you have financial software that can take care of our tox

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. why are we carrying all this buzz about internal things. so, really comes down to the cost issue. the sensors which you have to pay 100 bucks to get a decent sensor to measure the temperature. now you can, i'm not talking about the whole product but just the sensor, now you can buy with just a couple bucks which is extremely, extremely impressive. and also you can kind of see the sensors and collected data, the amount of sensor, amount of data increase exponentially. that creates a new opportunity for us. so let me go through one iots.

we already talked about this in previous presentations this morning. iot is really four layers. the bottom layer is the hardware layer, physical components, sensors, actuators, radios, chips you can touch. sometimes it's large as a car or airplane sometimes, on top of that you have a communication layer. essentially you connect these things. wifi. cellular network. blue tooth. whatever you can think of as connectivity. a lot of people think i.ot is te bottom layer, that's wrong. there's two more extremely important layers that adds value both from commercial perspective also from research perspective on top of that. so on top of the communication

layer there's 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 a agreed with one of the speakers that spokane hour ago. data, i lot of people say date you is new currency, it is extremely valuable. i do not agree. data has almost zero value. data is basically ones and zeros. there's no meaning. if you have a bunch of ones and zeros that doesn't have a lot of value. the value is created when you extract actionable, useful information out of this set of data. that's where data analytics comes in. that's where real value and business value is created. on top of that there's a service layer. this is the most important and

valuable layer. this layer makes a decision based on information collected. you have to make a decision what to do with it. it's not just visualization, you have to take an action. when you take an action that's where the 90% of the value of iot of the echo system is realized. the information flow is not just monitoring, also taking action, meaning, you are coming back, closing the loop. i'll give you one example. about 126 or 17 years ago about 16 or 17 years ago at m.i.t. they created a ring sensor to detect vital signs, you know, heart rate, oxygen, blood pressure, in a finger ring. and you carry it 24 hours.

wherever you go, if there's any problem, seems to be a problem, then you get alerted. so that was back in 2000. great job, right. so, you may ask question, that's a great idea, i want to give it to my fiance for my engagement ring, why can't i buy it from tiffany, right. yeah there's a technical issue. it's extremely tough to put everything into a small ring and then actually, first, first, the customers who will use this ring is essentially either patients or, you know, people who needs monitoring ring. so they're not going to be used to changing battery every day. once you have it there it has to go for months or years. that's challenging.

but in addition to that, the issue is much bigger than that. so when i was brought in as a white house solution fellow i was given a task to figure out why we are not seeing exponential growth of iot and cps in our world. okay. we see incremental growth. we talk about it. there's a lot of variables coming out on that. but we do not see the critical momentum like cellphone industry enjoyed for the last 20 years. so why is that? what was concluded at the time it's because the iot and cps landscape extremely fragmented. medical device company develop medical devices. a lot of the technology they are using could or can come from transportation system or health

personal smartphones, for example, or from disaster response system. okay. they're all developing these things in silohs, they do not have a lot of inter onner abili operate ability. so how do we create contents to scale. that's the core of the question. i'll give an example what it means by cross sector collaboration or cross sector example. crash-to-care scenario. you have a huge accident, pile on the highway. what happens? somebody's going to call 9-1-1, ambulances are going to come and they're going to start calling hospitals around. who has the the best surgeon and doctors available. if they're not available you got to call another hospital because

you have 30 injured people, for example. it's a mess, all right. in this example what you do today is literally use your cellphone and call hospitals. it's a command center. the example, the boston marathon incident years ago they did a heroic job to take care of the situation with the given systems. we believe we could have done better if we had a system that could coordinate, orchestrate and also connect different emergency response systems, hospital, triage system, availability of hospital resources and availability of the traffic, ambulances, obviously they want to all come in, they want to get there faster. can traffic system handle this. if you had something like this cross sectoral collaboration that we could have done better.

so few years ago we created a program called the smart american challenge. it was a collaboration program to bring industry, academicia, government agencies all together to really encourage collaboration with very specific goals. like saving lives, creating more jobs, more businesses, and improving the economy. ed it was a very success program and after that we took it and basically institutionalized, i'm still figuring out the government terms but i'm trying. institutionalize it and create a program called a global city teams challenge. and the goal is simple. we want the to create economies

of skill. health care, disaster, transportation, environment, without economies of scale it will just be science fair. just bits and pieces here and there. we want to create rep lickable, sustainable, creatable models. we want to bring in cities, why, because you experience your life every day with it. so with partner with the cities transportation, health care and environment we wanted to create teams with measurable impacts we have 100 teams in 120 cities all around the world apartmepartici. nonprofits, companies, universities are participating. so this is actually what we do, this is a smart city capacity

building program but health care is a truly important part of it. if you go to any city and go to the health care department or environmental department they work with the companies. obviously and they work with the hospital. but those are extremely fragmented and come one by one. the plan in new york city is not designed to work with the plan in boston or san francisco. problem is if every city has different plans and different home grown solutions will you never get the economy to scale. cities are not happy because they have to reinvent the wheel over and over. companies aren't happy because they have to sell their products more than once. it has to be customized. . whether it's a database. system. it's a big problem. so how do we address this issue? through a concept called action clusters.

instead of each city working with each company and university we want to bring in multiple cities, get them around the same topic of the shared interest. transportation. health care. air quality. asthma issues. also we want to bring in companies and university to call this around the topics. so outcome of this effort will naturally, because it was developed by multiple cities and multiple companies, will be rep lickable and scaleable and sustainable. now we've done this nor the last one year and have about 100 action clusters we put together. next step we want to go to super cluster. i'll go to health care example but it's related to other sectors as well. every sector, transportation, water and health care has

specific solutions they developed but each solution by itself cannot create real synergy. we have to bring them all together under one umbrella. multiple action clusters get together and create super cluster and create a blue print implementation plan that can apply to any city in the world. i'll give you a few examples what happens during the last three years out of this over 150 teams it. close loop health care as well as mass general hospital collaborating with a bunch of companies and universities as well, essentially this is an example that was also addressed in a previous presentation. there is a data set that you collect in your home. i mean you have a home secure system. you go through all these tests again.

they put ekg and all kinds of tests again. if you had an access to the data set that you're the collective for the last three years, wouldn't it be great that you could figure things out a lot easier than going through all these tests from the beginning one more time. so how do you coordinate different, the home health care system to the hospital health care system. bottom left. this is about crash-to-care scenario i talked about. scale project on the top right, installing fall detection sensors into senior living facility so that -- oh, 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're sick they just fall and can't get up,

don't have the muscle and strength to get up. they will fall there, down there, stay there for three days, they die. okay. and simple fall detection sensors can solve the problem. if you can detect it send a signal to the emergency department so they can check that out. i don't have a lot of time left. maybe i came too far here. so we cannot do this, i cannot do it by our self we do it with the partnerships, all these partners. all of these departments work together also all of the companies that work on iot in general work together. also this is international and global activity. one thing i want to make sure we understand is, we cannot, when i say we, the u.s. cannot do this by our self. and it's not right that we do it

our self because whatever we come up with may not work in europe or asia then there's no economy of scale. so we have to do it globally. we go through this process and the way we do match making and these things is by bringing them to an event and as one of the mechanisms, next week, tuesday and wednesday we are going to have a kick off to super cluster conference at grand hyatt hotel in washington, d.c. so if any of you are interested in health care we will have a separate health care session on it. please come and join. that's it. and i have 15 seconds to have probably one question. can i take just one question. yeah. any questions? all right. so i don't -- either i was perfect -- or this was not exciting at all.

thank you very much. [ applause ] ♪ we can cut the tunes. that music kills it. doesn't look like me at all but i'm randy johnson here at the university of commerce. i'm not going to add to the information provided today i will say i'm particularly proud of this summit, it's our fifth one. my goal on this five or six years ago when we went down this road was if we could bring together a lot of smart people and talk about technological advances and move the ball on disease treatment, wellness programs, we can call it a day and go home. i think we've earned our members

dues. on a personal basis i've experienced a lot of, 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 tid bit here in one of these meetings which gave me information to reject terrible recommendations several doctors gave me and stewart steered me in the different direction for the proper treatment i got. so the kind of things you pick up here are, i think, useful. but again, if we could sort of do our little bit. as we listened to joe biden the other day on npr, what happened to the cancer moon shot he mentions, well, it's moving ahead but we still have information in silohs. i'm thinking ten years we were talking about information being clustered in silohs. haven't we moved beyond that when talking about health information technology.

so it's frustrating when these issues keep getting repeated. all we can do is keep hammering away and keep moving forward. i would be remiss not to mention this afternoon we have another event. i hope you're staying around. we're not buying lunch in between. but there are good delis around the corner. it starts at 1:30. affordable care act looking back and looking forward, will look at what's going on with the aca. you can read headlines every day how well the act is going. if we can establish that maybe we can talk about solutions and going into next year i think that's important. i do want to mention jennifer limb and hillary crowe for their help on this with the department of foundation. we've partnered with them on great events, again, thank you

for all you're work. [ applause ] so, i did mention i think we will form a company and use your app in china as they get around the one child law over there. but we're going to get a little kick back on that. so thank you for coming. hope you can stay around for the afternoon. i think it's going to be a great event a little different twist with more policy and politics. i think you will find it very, very interesting. thank you for coming. ♪

every four years the presidential candidates turn from politics to human at at al smith memorial foundation dinner to raise money for catholic charities. >> i must say i have travelled the banquet service many years and how the absence of one individual could cause three of us to not have seats. >> mr. president i'm glad to see you here tonight. you've said many, many times in this campaign that you want to give america back to the little guy. mr. vice perfect he'resident i man. >> it's an honor to share the diocese with the descendent of

the great al smith. your great grandfather was my favorite kind of governor. the kind who ran for president and lost. >> now al, you are right a campaign can require a lot of wardrobe changes. blue jeans in the morning, perhaps. suits for a lunch fundraiser. sport coat for dinner. but it's nice to finally relax and wear what anne and i wear around the house. >> watch the dinner with hillary clinton and donald trump tonight at 9:00 eastern on cspan. and cspan.org and the cspan radio app. >> tomorrow night on cspan a conversation on race and justice in america. we will hear from both sides of the aisle how the next president

should approach racism and police misconduct. >> if she did something counter intuitive as bill clinton did with welfare reform she would be doing something bad for black people. because his policy was bad for poor people. the welfare reform. which is why the guys here at kennedy school like david elworth and others had a tough time being there and my good friend peter eddelman. in any case that would be bad. but if you mean would she be someone who would feel the pressure greater to do something for african-americans because she's white and she's a white woman the answer is she probably would feel greater pressure because african-americans are more willing to say something to

a white person than they are barack obama. we just want him to stay and don't die. whatever. what she would do, i don't know. >> a lot of people think donald trump just has no coheernt view of policy or politics. i would argue that that's not the case at all that his view is actually very coherent. he's a nativist across all spheres of policy. against foreigners competing for labor. i e immigration. against competition for free trade. against foreign policy. he wants to say i want the whole world to go to hell i'm not going to be involved in foreign wars or anything else he's in es ens a foreign policy nativist. everything one of his policies is looking forward and frayed of

engaging with other countries, particularly non-european kun theories countries. we can have a policy whether free trade is good or bad or how to make it work in america, but it's important to understand there's a strain about nativism and not about a real economic critique. >> the entire discussion on race and justice in america is tomorrow night on cspan at 8:00 eastern. >> this weekend on american history tv on cspan 3:00 saturday evening just before 7:00 eastern, ohio university benedict talks about the case where the court ruled it unconstitutional to try civilians in military courts while military courts are still operating. >> the milligan trial was part

of the debate designed to prove to the public that the danger was real and this the military trials were justified. and as we know, it worked. lincoln won the election of 1864. >> and at 8:00 chad heat on the origins of gay rights movement. >> the gay liberation front is playing on and building on all of the lessons that the whole other array of social and culture movements from this perfected are developing. the anti-war movement. civil rights and black power movement. women's liberation movement. they are taking the best aspects of those and building on them. >> then sunday at 6:00 on american artifact it's we take a tour of the woodrow wilson house where the 28th president retired

in 1821 and died three years later. >> he responded to the crisis by spending food aid to armenia and they were very grateful and a group of armenian woman were here in 1917 just after we declared war and presented this painting to president wilson. zb >> and at 8:00. ♪ neil oxman president of the campaign group incorporated talks about the history of presidential campaign ads beginning with eisenhower through 2016 presidential campaign. go with to cspan.org. now a conversation on bioterrorism and infectionous disease threats to the nation's

food supply. hear from former senator. and former house committee chairman, mike rogers. >> welcome. good morning. i'm dr. anand parekh chief advisor here. i want to welcome all of you on behalf of bpc and our cohost kansas state university to bioagro health policy and risk. today's policy reminds me of my of task finning in 1985 to work on intermission in widespread threat and two, pandemic plan in

response to h 151 bird flu, you will recall. in spite of much progress spanning both republican and democratic administration the 2015 bipartisan report of the blue ribbon panel on biodefense reported that the nation still remains highly vulnerable to biological threats. either intentional via biologic altererism or unintentional via nature, emerging and reemerging diseases often of animal origin. today's event will highlight the importance of agriculture in biosecurity as well as highlight potential strategies, tactics and policy solutions to ensure

the inclusion of bioagriculture in the next biodefense. we are very fortunate to have two outstanding panels of private leaders to lead. i'd like to introduce the moderator. of the first panel. our inspiring leader and founder of the bipartisan center jason to get us started. >> thank you for raising the bar i'll do my best. so welcome everybody. we have a really interesting conversation i think it's important because it's a conversation not happening enough here in washington. i will introduce our panelists and we'll get into a conversation among our leaders and then have q & a. first to my my immediate left senate majority leader certainty tom dashel chle

tom dashle. i will finally note that he is a critical voice in the conversation how to make washington work better, writing a book "crisis point" a thoughtful story talking about the opportunities in a clinton-ryan administration for the country to start governing again we will see the opportunities for governance around these issues. and really a pleasure to welcome dick myers here to the bipartisan center. he has a tremendous record of national service and courage, most recently taking over the interim presidency of kansas

city university six months ago. i wonder whether navigating the pentagon has prepared you for the bureaucracy of 200 tenured protesso professo professors. he is was in joint chiefs of staff in 2001-05 he was also awarded the presidential medal of freedom. we will soon be joined by our friend mike rogers. i will introduce him when he joins us. so just to get the conversation started i thought it would be useful to ask each of you to reflect a little bit on the broad question of why is agriculture security important? why is it a national security issue? why did we convince you to come here and talk about it. tom you want to lead off? >> jason thank you for those kind words and for moderating and your leadership here and

thanks for the plug for the book, i appreciate that as well. and general thank you for your commitment and the extraordinary effort you've made in this regard and the leadership you've shown in so many security context. it's a real pleasure and i'm flattered to be voinvolved with such a distinguished panel this morning. i think these are issue ys that deserve the highest attention and critical organization as we look at public policy in the context of national security. i don't think anyone disputes the importance of the issue. what i don't think has happened is we've given it the kind of attention it so justly deserves. i must have if i could from a personal perspective this is even more critical to me because of my own experience. it's 15 years ago this month that our country experienced a series of anthrax attacks.

several people died. my had office was the target of one of those attacks. it was a trying, very terribly difficult time for our country and people felt very, very vulnerable. that experience, i think, sensitized everyone to how enormously important this could be. i was majority leader at the time so i was right in the middle of the aftermath of that. >> congressman rogers has just joined us. >> and i was in the middle of the aftermath and can say from personal experience, regrettably frankly, that there was virtually no coordination. there was a real almost conflicting set of recommendations on how to address the matter and it was just a very alarming experience to me to see how poorly prepared

we were. well that was 15 years ago. we've now, i think, looking back over the last decade and half can say we've made some progress. but if you really think about it and you look at our prepatory position and where the infrastructure is today, frankly, i think we're far off the mark with regard to be where we need to be to avoid what happened 15 years ago we're having many of the same discussions we did a decade ago, right now. and so in that 15-year period, in spite of all the good intentions, we've had the pandemic in 200 7 and 2015. we had h1n1 in 2009. we had ebola in 2014. we had zika this year. there's absolutely no doubt in my mind that it's just a matter

of when, not if, the next natural or deliberate crisis will occur. taro tuo one of the most respected authorities on this issue in the country and a friend of mine said something at a congressional hearing earlier this year that i thought was write on the mark, as is so often the case with things she says, but she said she thinks these natural events out ght toe use in preparation for the deliberate ones, fact is, we're not ready for either, natural or deliberate. for the past couple year i've been in involved with the bipartisan blue ribbon panel on biodefense. it was last year we issued our first report offering 33 action

items in both, in three context, short-term, medium-term and long-term approaches to how we might address this circumstance. we addressed all the bioterror threats across the board but drilled down on a couple including the biological threat to agriculture. and as we analyzed just what we ought to do with agriculture in particular we focused on one idea that has so much merit, that is the one health concept as we look at threats to animals, humans simultaneously and come up with a comprehensive plan. we also said it is so critical that we elevate the leadership around this issue much more effectively than in the past and that it would be the responsibility of the vice president but somebody in the west wing has to be involved here and we have to elevate it

and give it the stature it truly deserves and we also felt the importance of creating some -- the wherewithall to deal with this issue and the response and recover period with real medical applications that just haven't been developed so far. so as i look at what kansas city has done and providing the leadership they have, the blue ribbon panel and now here at the bpc, i'm encouraged that we've elevated it. i'm encouraged that there's a call for higher priority. i'm encouraged that with this new administration whoever that may be, a new congress that we'll have a opportunity to build a broader context for this whole issue. but we got to do one thing we've failed to do for the last 15 years, we have to move from rhetoric to action. to find ways to put an action plan into place and i'm hopeful we can talk about that today.

>> braefore i ask you to talk about remarkable things happening in kansas city it's a pleasure to welcome general rogers. most of you know he was chairman of house select committee on intelligence. he's been a leading voice on this issue for a number of years. he worked hard to create and fund the biomedical advanced research and development authority in the congress and is the closest thing to tv sesh celebrity we have here at the bipartisan center. we look forward to hearing from you in a moment. general. >> tom thank you. it's always good to be with you.

-- insights much appreciated. the way i will set the stage. i think back to 9/11 and i was the acting chairman on capitol hill getting ready for a conofficialaticonfir confirmation hearing to be chairman and i got there a little before 9:00 just before the first tower was struck in new york city and went the second tower was struck as he's brewing up some tea. he wanted me to share some of his great tea and we called it off at that point because we knew something was up. and i think about how we thought about threats to the united states prior to 9/11 and there might have been somebody somewhere that said, you know e the way these non-state actors, terrorists from other parts of

the world can hijack airplanes and crash them into building. nobody really thought about that. it certainly hadn't risen to the level of anyone in d.c. caring much about that particular threat. as we look back we could have determined through the threads but at the time people weren't concerned about that threat. we weren't ready for it. maybe we should have been. we are still dealing with the aftermath. but in 1999 actually kansas city put out a report study on homeland defense. food, safety and security and preparedness program. threats that maybe even occur

naturally. but since then not much has happened to change the landscape. the recommendations in the commission report, the recommendations and thoughts here, not many if any have been acted on in a national way that makes us any safer from these kind of threats. 9/11 we couldn't have anticipated. here we know what the threat is that people around the world wish us ill. when we got into afghanistan it was discovered quickly that some of the sites that al kwieda is working to developing on six human pathogens and four crop patho agap

patho agagen. planning for terror on the united states has been around a long time. when you put in the system to deal with naturally occurring pathogens you also help with the terror piece of it. it's something we should be doing in any case. i think we should have a heightened state of urgency about deterring the terror piece of it. remember what osama bin laden said a lot of time, their economic goal was bleed america to bankruptcy. that was their goal. just recently one of the operational leaders of isis, recently killed by u.s. air strike, declared -- and this is

from daniel thighman from brookings, in one of his blogs -- he said here's what this isis leader said, the smallest action you do in the heart of their land is dearer to us than the largest action by us and more effective and more damaging to them. so the beat goes on. if they say things it's probably because they're planning them. it's not if, it's when are this will happen and will we be prepared. other countries are continuing to work on these kind of weapons. certainly north korea and other countries as well. with recent technology to manipulate genomes and so forth it's become a lot easier to

develop these weapons. there's some off the shelf technology that makes this a lot easier in today's world than it has in the last decade. i agree we're not ready in this country not nearly enough. livestock will be handled by the dean at kansas city state and she has experience with that which she will cover when she talks. i would like to talk about crops. not because kansas or south dakota is a wheat state this is because wheat with rice make up 40% of the caloric intake of the global population. 40% to wheat. so worldwide attacks on either

of them would have ill effect for sure. a fungal wheat disease exploded in bangladesh this year and it could kill 100% of the crop so they are burning their thoughts trying to eradicate it. the thought is it probably came across boarders in food stuff and finally made it to the wheat fields. wheat blast is something we work on at k state. there are solutions being tested but there's probably not going to be one solution that fits all cases for wheat blast. an in afghanistan was found air al koids mixed in with wheat flower sample.

flour samples. and it effects humans in low doses could cause hallucinations in large doses could cause neurological disease and amp u tagss. this goes back to the middle ages that show that in paintings. couple examples of pathogens that can affect our crop and can affect this $1 trillion ag economy we have in this country, 50% of our gdp. i think when people think of threats to food animals, food crops, they think that's just the rankers and farmers problem. they're a big, important part of the food chain but in terms of numbers a very small part. when you get to 15% gdp or there about this becomes significant

for our country. finally i say at kansas state one of the fun things to see in manhattan kansas is four very large construction cranes. you don't often see them in manhattan. and there's these huge construction cranes helping to build the national bioagri security facility in manhattan. they will be pouring concrete for almost two years. it was probably the deepest hole i've ever seen in manhattan and now it's being filled with concrete so that's where the plum island capability is moving and we'll hopefully see that come to fruition and hopefully will continue studying these diseases and coming up with ways to protect ourselves. the diseases in the n bath are the disease that's can transfer from animals to humans. so obviously really bad stuff. again, i will take you back to

prior to 9/11, there were some people that cared a lot about this threat, 9/11 we were surprised. this has been on the table for a long time. it's been talked about. i will say that i think crops are sort of the under talked about, under thought about piece of this. but in the end, what a adversary extremist, terrorist want to do is they want to the create in the populous distrust of their governance and the one way you do that is create fear. can you imagine major outbreak of any of these diseases, food, animal, food-crop diseases in the united states, it would -- there will we an element of fear, an economic impact, real impact in our diet but it could create an element of fear no matter how small and it's something i think we need to be thinking about and preparing for. this is -- these are almost the

perfect weapons because all of the targets are relatively soft targets. there's no danger to the perpetrator. they're not going to in most cases be injured by what they do. it will take some time to discover it especially with our current surveillance method chz are inadequate and then it will be very difficult to have attribution, who did this, in many ways it's the perfect weapon. i will save the rest of my time for questions. thank you. >> so mr. chairman, i expect you will now cheer us up by talking a little bit about congress having very recently been part of these discussions, how do you see this issue and where do you see opportunities to improve our situation. >> thank you. thank you mr. president and senator. good to see you again mr. chairman. this is a good time to bring in the drink carts because i don't know if it's going it get much better. if you look at what happened recently in syria there was

recovery of a laptop computer by a sooner onner atiperative senior operative and the information talked about a strategy for using biological warfare to further their aim. the recurring theme was it is much easier to obtain biological weapon than a nuclear weapon. maybe they need to refocus the way they use these kind of weapons. so the conversations we had, the frustration i sensed from senator dash chle\ daschle.

>> trying to get rid of the valley of death of vac vaccines and other things. the pandemic preparedness bill, both of these are bipartisan efforts. only problem is people have lacked interest in funding its full application what it means, so what we haven't done at the very essence of this is marry up what the threat is becoming and how we're dealing with the threat. we just haven't done it. we have huge institutions that deal with this notion of nuclear proliferation, rightfully so, it is well coordinated, everybody is integrated understanding the real threat of that weapons system in any form either a small radio logical dirty bomb up to a full blown nuclear explosion. so we spent a lot of time, effort, energy getting that command and control putting the

intel intellectual capability together and pursuing it worldwide with allies or on our own. i think we will argue today we need to do that now with biodefense. the enemy is much more sophisticated than they used to be. if you think of the recent outbreaks, ebola was actually studied by soviet scientists in the 70s as a weapon of opportunity. we saw it happen naturally in africa and candidly our reaction to it wasn't very good. we found we didn't have a lot of actions so the only thing left was to send in the military for mobile hospital units which caused a bunch of problems, thankfully other things happened that naturally took care of this problem. if it happened again today i venture to guess we're no better prepared than we were at the

outbreak of ebola. and we know intelligence services and adversary scientists have worked on that as a weapon system. we know for a fact rice blast is the other one we knew. kansas works on wheat blast there are some similarities. that was a weaponized system designed to deny their enemies of food. what do you do in military planning operations, you go after logistics first, if i can stop you from getting beans an bullets, i win. that's exactly what that research was designed to do. could you deny your adversary access to food products militarily. you extrap late that into the economics of a food change, houston, we have a problem. all of that is real. the recent findings that laptop computer is real. the sophistication of our

terrorists, days of scattered across the middle east are gone. they are much more sophisticated and advertising for people to join their fight. candidly one day someone will walk through the door and answer their million-dollar question. they have the right capability and right understanding of how to process, develop and then deliver a biological weapon. i agree with the general and senator it will happen it's a matter of now are we prepared to respond to it and are we setting ourselves up for beating it, disrupting it or reacting it to it. i think today probably not. >> drinks for everyone. >> all right so i want to move into a conversation. before i do i want to acknowledge senator bob dole, i was with the senator few weeks ago telling him about what we were up to and he noted four

things he cared deeply about. national security. agriculture. kansas and the bpc. i think he was flattering me a little bit to be included in that list. but he feels so passionate about this that he wrote a lovely letter that's out on the table and i encourage you all to take a look at that. so let's move to the what can we do about this? we understand there's not going to be a simple solution. clearly the nation is motivating a lot of resources to protect ourselves generally from these kinds of threats. i guess my first question is why has biosecurity not been on that priority list? mike, you indicated that we have a tremendous amount of architecture focused on the nuclear threat. is there some reluctance to engage this? >> a little bit of both, i think. if you look at, so, we have sub

sets in the united states government that track even the black market movement of nuclear materials and they are exceptionally good, and over a period of decades really they've developed this expertise and it's integrated back to the intelligence and military community. and there were ream things they could -- real things they could see to work on. we knew at one time north korea was trying to export nuclear components to iran. there were intercepts over a period of 10 to 15 years. same with bangladesh and other places you could see these materials moving around. it's a real threat plugged into a real architecture. it's critical work. you don't want that material going anywhere. we just haven't had that. so we have really bright folks

in the u.s. government who understand this threat very well but can't go back and plug into that kind of operation, integrated, established operation. it's pretty hard to go to congress these days if we can't get the pandemic readiness bill funded and we know we have these problems. the blue flu took 25% of the birds in iowa. one event. 25%. imagine if this was targeted event. we'd be in trouble in our food system so we don't have anything to plug into. so what we're trying to say is can we create that same kind of monitoring system and integrate it. i think we can. i think it will take investment and rethinking how to structure biodefense in that broader military community. >> i think mike pretty much covered it but just to

emphasize, you know, when you research the current literature, i did a google search for threats to our agricultural infrastructure last couple days to see what people are writing about out there. well, sad news not many people are writing about anything. if they did it's a long time ago. it just hasn't captured people like other threats that are maybe more tangible, strike the imagination in different ways. and two, when you look through the intelligence it's just not one of the priorities. so we have some people that are looking at that very closely. we have a fusion center out in topeka that does pretty good work here but there are no, not many other folks helping in that regard. we're just not gathering the intelligence. we know this is a coming, right, we know it is a possibility anyway and one way to protect yourself is you start gathering

intelligence to prevent it from happening and we're not anywhere near that. if we stumble across it that's fine but it would have to be stumbled across at this point. it's not deliberate. >> so i want to start thinking about the prioritization of these initial steps. tom, you serve on the blue ribbon commission which i think our other panelists are aware of and certainly the most prominent effort to call these issues together can you talk a little bit about the framework and what the feeling was about the top priorities. >> well you asked the question why is there a difference between nuclear and biological. i think there's two parts to the answer, first is awareness. people don't need to be -- people can see a mushroom cloud and know exactly the ramifications of a mushroom cloud. how do you see what we're talking about, no food, or the threat to food and the aspects

around the biological threats to aguilar aguilar. it's hard riculter. it's hard than we did in the last 4,000, because we are going to have almost 10 billion people. it took us to 1850 to get the first billion. $1 trillion of our economy, as the general just noted is his agricultural aid. so the awareness is there. that leads me to the second part of the answer. we need leadership. we need somebody who can take this and make it the priority it deserves to be. one of the problems we have is

siloization. you have nsc couple phone epbt. they are not coordinated like they should be. it is harder to take that very eclectic way and say we're going to meld the them together and integrate them in a way that produces an action plan that really provides a direction. and i believe in all the experiences i guess i have had over these many years if you're not in the oval office or close to the oval office, it ain't going to happen. it has not to be the west wing. it is is elevated above all of these agencies. just as joe biden is doing so admirably with the moon shot. it will take a moon shot like approach led by the vice president or somebody of that

stature to make this happen. >> we have mixed in the country with the czar idea. some very successful. it was a focused effort led by the congress. when the white house tries to coordinate around one person who is not subject to congressional oversight, we have seen the tension there on the basis of separation of powers and institutional ego. sharon rogers, how do you think that can play out? obviously there is a desperate need for coordination. how can that happen between the executive and the legislative branch. >> my mom used to say an invitation to the party solves

all of your parking issues. meaning park on your neighbor's lawn. work with me. my mom was a brilliant woman. i don't think it will work. i think you need some representation from, a, members who are keenly interested and getting them participate anything that conversation. so if you had the vice president on the coordinating council on biodefense, i recommend you bring folks from the house and the senate who are interested in the issue and committed to being a part of that. i think you will get much more volume. congressional reform could be co we could have four panels lasting six days. >> there's still oversight? >> maybe not these days. i think the dni told me one time if there's an event he has to appear before something like 159 committees. i forget the numbers. it's outrageous. he will spend a lot of his time

running around different is subcommittees who have a little slice of jurisdiction on this. i think it is a horrific waste of time. i would like to see it would issues like this. is and park on the lawn. >> we have the pleasure of working with the 9/11 commission. the single most thing they are most frustrated was that very argument. there are 103 committees that dhs has to appoint and report to. when you have 103 bosses, you have no relationship. another corollary to what they said. >> both branches of government can work well together. one of the advantages of thavin the president appointing somebody is at least it would

get the executive branch organized. they have to get their branch together as well. there would be a lot of benefits to doing this. we just can't assume the executive branch is well organized for particular effort. different departments have different views as to what their responsibilities are. somebody has to lead that. it only happens, i agree totally, having been through a couple wars now and seen how we try to harness all national power to bear down on afghanistan or iraq. the only way it works is if somebody is in charge. somebody has to be in charge on the executive side for sure. >> so we're focused a lot on the federal questions. but if this is going to be a whole of government response, there are important roles at the state and local level. i wonder if you are aware of those efforts and to what is extent is this the focus of the

problem. >> kansas and kansas state have a unique program to dedicate sort of a national attention to the issue. and really begin to put the action plan together with research and with coordination unlike anything we have witnessed before. and certainly the general can talk that. but i think some states have begun to put plans together. there's a requirement that each state have a plan. but it isn't coordinated. it isn't really understood from one state to the next. there is srepblts interactive experience. it begs for a framework even though there is a critical role to play as we saw after 9/11. and virginia and washington. but that has to emanate

someplace. right now it doesn't exist. i give great creditors to governors who elevated it. but a lot need to be done for the national framework for a national response. >> you referred to the state of kansas. we have intelligence fusion center in topeka. the word unique applies here. according to the folks in homeland security, it is unique. but they are the one group that are looking through all the intelligence trying to connect the dots about what might be coming our way in a nefarious sense. and there's a lot of research done at kansas state. dr. beckham knows a lot more about this than i do. it funded centers to work the surveillance problems so if an outbreak occurs can, it gets reported quickly and you can

start to come up with protocol toss deal with it. that is in jeopardy. the only program i think of its kind out there. it has been pretty successful. it is only going to live so long. so the premise is exactly right. a lot of this has to happen at the state level. it can happen. there are a lot of people ready for action. but better coordination, appropriate funding, whatever that means, can make these things come to life. >> any final thoughts before we open it up to questions? >> we saw this right after 9/11. we were trying to put together pots of money to get down range to help states and emergency responders. even with the pandemic issue, what do we stockpile, how do we get it there. and the states have to be part of that solution on two phases. one, i used to get people coming into my office. god love them, as my mother

would say, who wanted the big command centers and population for it. but they had to have everything that the major urban areas had. and it made no sense whatsoever. and it was pretty significant. that pressure came to congress. even wanted what everybody had. we to the floor that much money. i would love send the most sophisticated technology. i can say that now that i am no longer in congress. how do we have to get the resources part right. b, last year the homeland security did some work. and people didn't know where to go to access the materials of which they might need to be prepared. they opportunity know who to call. they didn't know how to go through the process. i don't care if it is radiological or therapeutics or

even the stockpile of anthrax and who can get it, how do i get it to my first responders. there was no clear path to understanding how that all happened lots of materials we purchased along the way has now expired. the shelf life is over. it hasn't been deployed. what do you have to do, go back and repurchase all of this also sit in the shelf five years. we've not to get that piece figured out soon. and i think the