focusing on a chronic condition is important. and our focus has been moving upstream. we want people who have diabetes to get optimal care. we are looking at how we stem the tide of this epidemic we have been living through in our lifetime. so we have really been advocates of utilizing the national diabetes prevention program because it is an evidence-based intervention. it's got a package out there that you can count on. we've used that within our company on a widespread basis. it is be able to anybody on our plan an opportunity to participate in the diabetes prevention program. in addition, we have worked in the communities where we have a significant presence of population to create sustainable system change and looked at the availability of these upstream actions that can identify and intervene before somebody

becomes diabetic and facilitate their progress to not becoming diabetes. honestly, we are seeing pretty good results. >> can you give an example how -- what kind of behavior change you're seeing and what, very specifically what are the triggers you're push to go he get somebody to the gym or make them stop eating whatever they are supposed to be eating. >> it is widery researched, a highly effective program. what happens as you measure the impact on people's body mass index the, their weight, and their behaviors, they're really focused on better eating and activity levels. so collecting those metrics is how we are measuring the progress in that program and what we're getting. so as far as our general health programs, we have ava right of things we are doing in our

population broadly. we are just talk building only the diabetes prevention program. we really provide a health advocacy model. we focus on facilitating our culture and environment in which people can leave quality healthy lives and that by being at their workplace it actually helps them to live a healthier life than if they weren't in our workplace. >> how does an insurer, for he each of you, get somebody to do what they know they should do but often don't get off the couch? >> that's really hard. i was talking with will and david at breakfast about behavioral economics and the irrational decisions we all make around our health, myself included. so on a positive level, the metaphorical cloud, the rain falls town into the data lakes.

we mine the field from the cloud to the lakes. we are doing okay. we have our value based programs, ac on os. we have 6% lower total cost in diabetic -- persons with diabetes but they still have diabetes. and 9% biomarker a1c which hardly tells the whole story. a resident came into the clinic and said, doctor, the patient is doing well. i go in and the guy has -- one of his legs is amputated. he has a care taker. he is legally blind. i said we're not doing okay with this person. you told me a story that sounded like this guy is okay because his blood pressure is okay and his hemoglobin, a1c. we're doing okay by taking information and sharing it with our clinical partners and they in turn are driving towards metrics, medicare, starr total

costs. but we have so much more to do on tack he elling the causes of diabetes, the behavior change. i'll admit, we've got a long way to go. >> so the total population approach would suggest that you want your doctors to practice the best evidence-based medicine that we know, has them giving advice to the people with diabetes. so that's step one. and to do the that, in minnesota, we have a standard approach for all payers and providers in minnesota. the second thing is you want to promote programs that address the key behavioral issues that lead to diabetes. and obesity and nutrition is a tough nut to crack. we have not made as much good

progress there. but with the control of diabetes and the measurement standards that we hold in common, we have managed to improve the consistency of clinical practice across the state, cut the rate of on complications by diabetes by over 30% in the entire state population. so we're not talking about one clinic. we are talking across the board through those approaches. and then what we need to do is reach out, which we are doing now, to educate children in the schools about healthy eating and behaviors. we need to partner with public health in terms of legislation in minnesota with respect to smoking and other risk factors in the workplace. you know that can be co founding factors. the four buckets of health care, behaviors, socioeconomic factors and environmental factors, walking paths to encourage

people to be active in their communities are all part of the solution, both the immediate solution for people with diabetes and the upstream solution in terms of people at risk. >> i find it interesting here we are talking a lot about health. and i think the slide and the graphic said leaders in health care investment. we are talking about leader in health investment. as george has pointed out, health care is a piece of the solution. >> normally it is is after you have gotten sick. >> right. >> what we really want to do is achieve health. so we need leaders in health investment including health care. i think we're focused on health. >> i will echo the run stream that you talked about is important. one of my good friends is a well regarded family physician. he said the wiser i get the more

i'm convinced headache do for people is when i talk, encourage and coach and change behavior, which is really hard. it is not just mds, dos, but nurses they are increasingly take thing on more. that culture of health as opposed to health care is aspirationally where we're headed. >> another buzz word in health care is related to this activation is patient engagement. it is is one of those terms that can mean an awful lot and can mean nothing. to create oren courage health. if the patient goes home and sits on the couch eats buttered

popcorn, not to pick on popcorn but that fond in my head i have three people in my family and one who doesn't exercise. he's not as healthy as the others. in terms of how all of you come at this pace. and sometimes we talk about patient engagement. they say, yeah, we have a website to make payments instead of being on hold. i think that is convenience. i don't think that is patient engagement necessarily. so how do you -- by patient -- it can be someone who is healthy as well. how do each of you think about the tools that you have in your organizations to engage, to get the patient to understand. the individual to understand i have to do this, that i have to own this, that i have to be part of this. going to the doctor and listening to something doesn't do anything if you don't then behave differently or keep

behaving in the way you should be behaving. >> it is a very important question. and i think the answer is having a thoughtful strategy. and the strategy for us has several components. we have a strategy called our corporate health strategy whereby we are looking. and it is multiple components. we have policy related to smoking, for example. nonsmoking on our properties and workplace. so policy plays a role. >> is there also a higher premiums for people who smoke? >> on life insurance, yes, there is. >> but not for the health. >> so policy matters. and then the second thing that we focus on is how do we create a culture and an environment? and we have had for many years a healthy workplace index, which is a measure of all the factors that can create an environment that facilitates healthy people.

that is axe asses to healthy food at the work site. places to exercise. looking at the stress and the environment and the capacities around communication and the use of an opportunities where peers influence behavior. having a culture which talks about this and leaders give it airtime and speak to it. so there is this healthy workplace. and then we have individual health assessments and counseling and coaching. so all of that is a part of the strategy and looking at the way we design our benefit plans that facilitate that. and then i mentioned the community. so we will look at the community and how we as a company can participate in achieving a healthy environment in the community. we have our workplace environment as well as the community.

we can use our fiphilanthropy. advocacy is another mechanism we can help to facilitate at the state and local level. looking at how we partner in a multistakeholder way to get everybody working on shared goals at the community level. so i'm trying to illustrate that we have a strategy that is ours and a strategy of engagement at the community level. and it does take all of that to get that behavior changed. >> for insurers, what are the tools to get the engagement? besides the portal. >> we are also a delivery system as well. so it's integrated. this particular strategy also has to do with place in terms of where the people are receiving care in the neighborhood it's in and tailoring the approaching. so some of the neighborhoods, yeah. and the states that surround it

as well. so you have to the talk about, again, an individual approach, which is being sensitive to the culture and the health literacy of the people involved. being able to help them learn at their capabilities and reach out in a way. being culturalry sensitive. people have different trusts in terms of that education depending upon who is saying it and what they look like and whether they're different from the people that are receiving the care, for example. and then, for example, and i'll give this in terms of a screaming strategy for places where transportation is an issue for people getting to the clinic because of socioeconomic factors, actually compressing the care so the distance between recommendation and receiving the service is in the same visit as opposed to disconnected will increase rates. and tracking your performance and turning your quality improvement tools into

diagnostic tools to do the root cause analysis so you can figure out what approaches to use. that is the delivery side. on the health plan side, it is is very much matching that up with the whole population approach and outreach in terms of the programming cathy was talking about. so we have units that work directly with employers on health risk assessment, workplace, you know, wellness programs, 26 clinics located with employers, you know, that kind of outreach to make it more accessible and likely for people on the job so they don't have to take time from work. it increases the access and the ability of people to engage. >> a specific example. we are not a delivery system. increasingly we are working in a very collaborative way with our clinical partners and purchasers. that is a very, very important and profound change. we can do better in this area.

in clay christianson and skwrje grossman, in blessed memory. it is is like 85%. so we are not doing something right. again, i will reference how to change when change is hard. we've got to figure out a what to smooth a path so we are able to see groups of folks going down a better path. again, using the 401(k) versus wellness. we're not there yet. one positive example, something joy said about getting into the communities. we did a peer coaching pilot with 100 persons with diabetes and getting the usual care. usual care is pretty good.

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

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

and earn their trust that everything that we are doing and offering to them is truly in their personal best interest and behave and act with integrity that we are here as their health advocate. and we have attached this to other things in the company with high participation rates. so we have been able to be very successful. so i would encourage people to use a marketing mind-set and create value to create participation. >> the interesting thing about tech is that bob blendon at harvard business school during a survey of experts actually asking the questions what are the factors that drive health. the experts will overestimate by a factor of two to technology and personal care by a factor of two to three. so we as human beings want to

believe we are in personal control of our mortality when in fact, we need to collectively work on factors. those are far more important than we would estimate. now, having said that, we've got a lot of apps and technology that we are deploying to help motivate people to change their behaviors. but the science isn't in on that. we have a lot of faith in terms of doing that. and our research unit is conducting studies whether there is in some of that. on others, in terms of workplace wellness, we have some good data about impact for companies and productivity. >> are the companies that use those, the monitors, fitness trackers, exercising and playing soccer anyway? or do we know whether it is is making people do more or they are just enjoying tracking what

they would be doing anyway? >> i do see selection bias. i wear one of these. my heart rate is 85. down to 79. i'm normally around 58. i must be a little bit nervous up here. so just a personal observation folks that are selection biaseding going to the gym anyway and doing these things, we are working with clinical partners are biodirectional data exchange. we have been looking at ava right of application of tools and technology certainly some of our groups are very invested and doing a great job with the patient portal, which isn't exactly an app. but nothing that we have seen or observed or done yet that i would say is very profound, the proverbial game changer as it relates to a wearable or

something like that. bob has the -- our key note speaker had insights and ideas on that. from our perspective, we vice president seen anything that's been profound. >> okay. it's time to wrap up. i guess my closing thought was, and i actually shared with them on the phone, i thought it was people buying companies. i was just reading the headline, i thought it was about consolidation or anticipate trust. getting big or getting small. then as i figured out who was on the panel and we had the phone calls, it really is and i hope they have been able to show you, a different kind of investment. it is an investment in the population that one way of getting these costs, maybe not down to the way we would really love them but a way that we can manage better does have to do with thinking differently about what's health care what is health and what we call

population health. so thank you for joining us. >> thank you. [ applause ]. good morning. good morning. i would like to thank the u.s. chamber of commerce and u.s. chamber of commerce foundation for actually organizing the summit. today we have the business community, we have the health care community, we have the policy community that altogether

here. we don't off get-together. we need to do this for the future of health care. some of you may not know novant health. it is a $4.1 billion not for profit health care system comprised of 14 hospitals and about 500 clinics and ambulatory sites that provide advanced medical treatments throughout north carolina, south carolina, georgia and virginia. and in fact, we treat more than 4 million patients annually in those sites. again, not for profit. we have been with novant health for the last four years as ceo. in these days when i look at the future of health care, i describe it this way. we are redesigning a plane at

the same time we're flying it. now, think about what i just saided. redesigning a plane while we're flying it. the national imperative is clear. we must improve the patient experience, improve population health, and obviously reduce costs. and we must do this at a time that demand is on the rise. we have a rapidly growing senior. hraeugz who obviously need the most care today. and we have a group of americans that are newly insured in our health system for the first time. so just novant health experience, the number of people has grown over the six years

since the law was passed. for example, and, again, we operate in states across the four states that did not expand medicaid. for example, our physician office visits are up for 3.8 million in 2010 to over 4.1 million in 2015. no problem when i describe that, right? well, i forgot one important point. the payment we received from insurance companies, medicare, medicaid, are stagnant and declining. and don't forget our payment structure is changing from one based on volume to one based on value. patient outcomes, patient satisfaction, readmission rates are important factors in our revenue stream. we are all being held to much higher quality standards.

we're also sharing risks today. our ability to treat fifthly and effectively will allow us to succeed financially. so all of what i just described adds up to a challenging business environment. but i want you to hear me. we are up for the challenge. again, we are up for the challenge. this is an important aspect of what we've been doing. so first at novant health, we focused on treating the individual rather than the disease. this means offering new access points to consumers by expanding our provider office hours and providing off-hour visits to better accommodate our patients's busy lives. and using new technology to our advantage by offering online

scheduling. review their lab tests. review their physician notes. schedule an important and refill their prescriptions. many of you are participating near hospitals and health care systems that offer these services. if they're not, perhaps today you may come and join novant health. we recently conducted a study that showed how consumers wanted to be treated. they value being treated with respect just as much as they value receiving effective quality care. that's a very important insight. people want to feel respected whether they're in a hospital or a clinic. and we work hard to honor that wish by training our doctors and our nurses to empathize with compassion that delivers the remarkable patient experience that they deserve in a very authentic personalized way. second, we have invested heavily in the health care technology.

and we are big tphraoefrs that health care technology is important and we value it. tphrebgs, we put technology in the hands of our nurses. they go room to room, patient to patient, to see what the treatment plan is for that day. recordkeeping happens in real-time with the nurse and the patient together. this adds up to nor time at the bedside and less at the nurse's station. at our case at novant health, 76% of the shift is on direct

patient care in the patient room. so the industry average is less than 40% of a 12-hour shift on direct patient care. so this has helped to improve the patient experience. it's helped reduce accidents and falls inside our hospitals. it has been good for nurse morale. guess what, they get to do what they always wanted to do, take care of patients. third, we invest in the health of our doctors and nurses. we believe in order to have world class physicians and care takers we actually have to in vest in them so we can deliver world class care to our patients. physician burnout and nurse burnout is a significant and largely unrecognized threat across the country. despite the surgeon recognizing physician well-being as an important priority earlier this year.

you may be surprised to hear that on average one physician a day commits suicide in this country. a recent survey showed 50% of doctors reported feeling burnout in 2015. 50%. i would tell you burned out physicians, punched out nurses are probably not delivering the highest quality care to their patients. that's why it is so important to know our doctors and nurses are in good health. so we have developed a homegrown program to help our providers address burnout and develop the skills they need in this new health care environment. since launching in may of 2013, the program has helped 300 nurses regain their commitment

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

but i believe there are policy changes that are needed if we are going to achieve. we are heavily regulated by the federal and state level. the rules and regulations are sometimes contradictory. in most cases were written two deck the aids ago for health care systems that frankly no longer exist. for example, current rules and regulations make it risky for doctors and physician assistant toss collaborate on care. it bars hospitals from sharing an electronic health record with certain outside physicians. it creates financial disincentives to follow best care practices and bars hospitals from making specific recommendations about can which skilled nursing facilities to can consider after discharge. even if we know, and there's data that shows that certain ones deliver higher quality care.

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

practitioners, and provide assistance to patients to maintain their health when they return home. and we believe in it so much that novant health will be working with the hospital association and the next congress to address these opportunities. we also believe there is room for collaboration among can competitors such as information technology, revenue cycle, human resources, purchasing. in addition to back office functions, we believe that we should look at sharing and some clinical investments with some competitors is and not duplicate efforts, duplicate spending. we believe that we could save millions and millions of dollars, many that could be reinvested in unmet community health care needs. quality improvements and population health. but today we are prevented from doing this under current anticipate trust laws which were written more than 20 years ago

for a health care system that looks nothing like the one we have today. this is an exciting and extraordinarily challenging time for the health care industry. if we're going to achieve the national imperative of improving quality, reducing inefficiencies bending the cost curve, we have to be bold and innovative in a new way to deliver this care. we need policies for these to the take place. it would impact health care systems across the country to better serve their communities, to realize the national imperative to provide higher quality and at the lowest possible cost. meaningful change, especially in collaboration cannot move forward without these policy changes. in closing, i want to leave you with a message that success is possible. progress can be made, quality can improve, and savings can be

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

consumer health can improve. and we at novant health prove that it is possible to bend the cost curve. thank you once again to the u.s. chamber of commerce, u.s. chamber of commerce foundation for hosting this summit. and i look forward to taking questions. thank you. [ applause ]. do we have questions? yes. >> (inaudible). >> i will. it is a program we designed, a three-day program. it does really a quick look at what really happens and how do people see you. for the record, as an individual, as a practitioner. so how do you believe you see yourself, how do others see you in your clinic, how do patients see you. and then we get into behavior

patterns that either drive success or drive people away and drive chaos both in a clinic, practice, and at home. we are looking at whole life. how do we take that three-day course and take it in a shorter period of time but still get very similar results. thank you. >> carl, great job. with the comment that you made about having your employees go to high performing, high value, what's been the backlash? you have a large medical staff, i'm sure, at your many hospitals in five states. so i have the list of being high value, how you dealt with that political fallout. >> we put a stake in the ground, steve. and what we said we were going to do is absolutely what we just

laid out. we offered incentives with lower co-pays and lower out of pockets for our employ increase and team members to the select as doctors the. we had some questions. but what the beauty of it, we had physicians working with physicians to help others get to that list of where you would want to be that provide open access, high quality care, and efficient care for our team members. others? yes. >> well, the movement for pay for services to pay pore performance and value, i have been on the quality alliance committee, et cetera. i don't want to get too technical. it can be technical times 10. how do you really measure the value of services in your group? is it subsequent patient surveys

et cetera. revisits to the -- retreatments of the same underlying disease, recidivism or what in a nutshell if you could. >> value is what we are all measuring. i will start with -- the first thing we did is something very simple. in our group we measured our quickly one of our team members could get inside and get an appointment with one of our doctors. we opened up access. so the first thing for us is did the patient, did the consumer see it as value. those are the things we focused on. for example, these video visits -- we actually had primary care offices that run like urgent cares to keep the lower price points, lower options. so if you think about that, we directly focused value through the eyes of a patient, through the eyes of a consumer. and through that we obviously have a score card that we monitor looking at how many visits can we reduce, can we get

people to the right place at the right time at the price. and that's how we're looking at value. >> anything else? >> just a quick comment. i just saw some data yesterday, so it's fresh some my friends. persons, patients, consumers, call it whatever you want, access parking courtesy. all the quality measures. all that stuff we pay attention to. so the parking access courtesy were like 4.6 and the quality measures were .6 in terms of what the person perceived as being -- >> just to highlight that for you. i talked about our electronic health error. what i want to share with you, we have 700,000 active users utilizing our electronic health record today. it is because of the access points. our doctors and providers. our patients as they come in. if you want to stay connected

24/7 the best way is through the electronic health record. we have the constant video visit. it gets reported inside the electronic heating record. it is all there for convenience. access is a key part for a lot of our team members for not only selecting our providers but to really engage in the way we needed them to engage. >> thank you all. [ applause ]. >> thanks to katie and hillary and the whole team not only for the avatars but for this important conference and for bringing up some of these important points in health care.

i'm thrilled to be here and give you the entrepreneur start-up perspective. so our bodies are radiating data. since the beginning of time, your bodies have been radiating data. but for the most part we have ignored these data until something goes terribly wrong. you wake up with a sore throat or achy back. and then you start paying attention to taking your vitamins and getting more rest. or your physician calls you and says, your cholesterol levels are through the roof. and the data that your body had been radiating are now making you realize, well, now i need to start paying attention to my diet and my erz exercise. now we have loads of gadgets, sensors and gizmos to collect the data that our bodies have been radiating since the beginning of time, analyze it ourselves, and make improvements to not only our wellness but our

health without even talk to go a health care provider. this is a profoundly different model in health care where wearable sensors are taking us. it dove tails on wellness empowerment and patient empowerment. we will touch on both in the next few minutes. but think about what might be possible. if you can take these data that your body had been radiating examine make the most of your body and your mind. this is prior to things going wrong. you are all familiar with the activity trackers, the fit bits, jawbones, nike fuel, some of which are still on the market, some of which are not. it has been ground breaking to get people thinking about collecting the data from their bodies. but these activity trackers are just scratching the surface with where wearable sensors can take

your wellness. stress is one of the most important trackers that people are wanting to see in wearable sensors. now we have trackers that can simply connect to your waist band all the way up to head bands that can help you with your meditation process. and all of these stress trackers are able to identify what makes you anxious, what makes you stressed, what are those triggers and how you can improve that. i like to call this quantified mindfulness. think of all the health care parameters that could be improved things as simple as these. the other is sleep. you may have noticed there are a lot more sleep trackers and sleep apps out there. everything from a free app all

the way to more expensive sensors that can identify your sleep patterns. these products are telling you which nights you have good sleep, which nights you're losing sleep. again, the triggers that can help you improve your sleep. and i like to think of this as sleep mindfulness. what's interesting in the irony is all of this technology is what caused us to be stressful and lose sleep. now we are using technology to bring us back to the mindfulness. but that's okay. it is all about behavioral modification. sensors are really changing the way we live our lives. there are so many sensors on the market, how do we make heads to tail of them. there is wellocracy with a bunch of tables that will compare and contrast. this is one about sleep sensors and devices. so you can just click on this

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

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

5% said yes. so there is a gap here which is really causing a slope uptick of these digital wearable sensors to help the health care practitioner. now, the reason could be there really is no approachable intuitive technology with actionable outcomes. perhaps the physicians would be more likely to strongly recommend these products or the patient would be much more likely to go out and try these products if they had actionable outcomes and they were easy to use. well, now i get to talk a little bit about my company, primatemp. pri priya identifies the subtle changes before ovulation. when she is most fertile it sends an alert to her

smartphone. the is a ring like all the rings around the decade. you may have heard of nuvaring. they have been on the market 25 years and they are drug delivery systems the for women. it is contraception, delivered to her. she removes it at the end of the month. we have simply taken the medication out and put a temperature sensor in. she wears it a month at a tate and waits for that notification to be sent to her phone. yes, it can be sent to her partner's phone as well. so this is truly predictive, permanentized digital health medicine. and it's also a subset of the empowerment story which is women's health and women's empowerment. it is a very interesting time to be a woman in this day and age in history. looking at the health care market specifically, the global women's health market is scheduled to grow at 4% the next

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

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

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

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

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

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

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

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

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

technologies with each other or competition. phillips and qualcomm have recently collaborated, which is going to require phillips to branch out from their very closed phillips system they have had with data analytics and start sharing their data from their interesting sensors and devices. jim malt put it very well from qualcomm. the last thing a player like united wants is ten different one off solutions that don't inter op operate and have nothing do with each other. but the vision by jared jocelyn from verily said on duo, which is the diabetes program that sanofi and apple collaborated on can sell insulin or novartis, nothing to do with sanofi, but it is about the customer. the vision must be shared between health care and technology companies for these collaborations to be successful. so in closing, your body is radiating data. now those data are in your

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

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

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

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

with circadian rhythm showing changes in gene expression, as i mentioned, cirdacian 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? >> i think it is building off the gentleman's question, the individuals using the approximaters nal devices. those likely could benefit the most can't afford them. so how are you tracking any of that information? are you able to say there are differences? >> well, that's where the companies that we're collaborating with at kaiser are choosing to -- our products won't go down a pathway since there is limited reimbursement

for fertility, but aetna and kaiser would like to offer them at a deeply discounted rate. from an insurance perspective, consumers are choosing their own insurance company, based on what they can provide. so i think the insurance companies and the larger ploys are starting to offer these at a deeply discounted rate. aetna 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 -- own a product that they could probably not purchase on their own. thank you. [ applause ] ♪

all right, good morning. my name's christian garcia, managing director for 776

ventures, a seed fund incubator here in washington, d.c. i'm joined by three health care executives ranging from the payor and provider side, and we're going to be talking about health care delivery system reform. maybe to kick things off, introductions here with you? >> sure. good morning. my name is will sneeden and i'm from aeon. aeon is the largest provider of health and benefits, consulting and administration services to employers in the united states. my role is i'm the national practice leader for our health and medicines consulting group in the u.s. so, i'm going to represent the employer view in the context of the health system transformation and the stake in the game that the employers have. >> good morning. my name is jesse 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 created better opportunities to access to 24/7 banking, created opportunities to better understand their segments through consumerism and segmentation. we'll talk a little bit about that. you've heard about 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 bucket is to better understand both that patient population, but more importantly, we've identified six segments within that patient population. and within those six segments, some of them are 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 an inefficient 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 prior 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 medicaid ac ochlt that's hopefully going to allow us to engage that patient population in a very different way. that population doesn't have cost incentives, doesn't have co-pays or deductibles. and so, their consumption of care is very different. their incentives are nonexistent. so, we're going to try a new set of engagement tools starting december of this year to engage that population in a very different way of care. >> so, a couple things i heard, common themes both early this

morning and from you guys is just this notion of patient engagement, right? and i can tell you from the investment side, from the venture side, there is a great deal of emphasis and excitement on how you drive quality and outcomes through engagement. but frankly, you know, people are experimenting with different things, a lot of stuff doesn't work. so, what have you guys seen in terms of innovations or technologies that are really driving quality and outcomes through engagement and what has been working or what have you seen on that end? >> look, i think technology's really important, but there's two sides of it. on the provider side there's no silver bullet. there are many engagement tools that we're using on the provider side to help them, "a," educate them about their care practices, the variation in terms of practice delivery that we have across many of our physician offices and across the hospitals. and so, electronic medical records, ehr, whether you're talking about e-clinical works or patient ping, which is one of the most recent we've implemented as of about 12

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

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

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

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

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

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

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

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

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

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

like going from point "a" to point "b" is easier, finding something online is easier. everything seems to be getting easier, and yet, the health care experience in many ways does not, right? so, kind of pulling on the thread of who owns that patient experience, who owns that experience of how to help the consumer navigate through that. usually when i look for a doctor, the first place i go is my insurer, right? and 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 hip democratic oath, but i think there's some question about that right now. so, where is that most objective, unbiased opinion going to come from? i'm not sure there's a great answer to that but that's one of the problems. you have a system where the dollars flow in a very different way than the consumer decision is made. so, i think the consumer naturally have -- and i almost hate using that term, the patient, the member, the consumer, the person really needs that sort of unbiased help to know they've got someone thinking fairly about their personal interests. that said, the systems themselves, we have such a complex health care system. and you guys have to send patients to lots of different places in order to complete an episode of care, right? and it is natural that the health system itself needs to help direct where the patient needs to go and what order they need to go. so, i think once they're in the system, the navigation probably starts at the provider. let's face it, health care happens where the patient and provider come together, and that's probably the starting point. >> i'm a big believer in

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

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

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

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

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

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

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

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

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

i think medical education will look different in the future. we talked a little bit about what we're hearing from our consumer populations, and we clearly know that they want to be respected. so, i think how we train our doctors in the future 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 underestimate 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 inordinate 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 is nothing more than iot, internet of things. cyber means connective. internet. and physical means things that you can, you know, touch, feel and so. so, cyber-physical systems is iot. what it really means is a hybrid system of physical components and connectivity and software. virtually everything you see these days kind of falls into this category, smart thermostats, smart vehicles, smart health care, smart sensors, anything with the word smart, that means you have something with a cyber component on it. by the way, please do not confuse the cybersecurity. that's not cyber-physical systems. when we talk about cybersecurity, that's a whole different world, and i'm not going to talk about cybersecurity today. so, why are we talking about iot and cyber-physical systems,

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

next wave or revolution. so, by the way, i can't believe it's going to be 80 degrees here and it is 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 i.o.t. they hired me as a white house presenter fellow to work on cyber fiscal systems. and three years ago was about the time that all this buzz around i.o.t. started to come up. by the way, i.o.t. is not new. it's been around for probably decades, more than two or three decades. it was called m to m at some

point. it was called smart systems. it was called all these different names. so why are we hearing all this buzz about internet things? so really it comes down to the cost issue, the sensors, which you had to pay 100 bucks to get a decent sensor to measure temperature. now you can -- i'm not talking about the whole product. i'm talking about the sensor. now you can just buy it for a couple bucks, which is extremely, extremely impressive. the amount of sensor's data increases exponentially. that creates a new opportunity for us. we already talked about this in previous presentations this morning. i.o.t. is really four layers,

okay? on the bottom layer, there is the hardware layer. there's physical components, sensors, radios, and chips you can touch. sometimes this is as large as a car or an airplane sometimes. on top of that, you have a communication layer. essentially you connect these things, wi-fi, cellular network, or bluetooths. whatever you can think of as a connectivity. now, a lot of people think that i.o.t. is the bottom layer. that's wrong. there are two more extremely important layers that really adds value both from a commercial perspective, also from the research perspective on top of that. on top of the communication layer there is this data analytics layer. this is where you take the data collected from bottom layers and

extract useful information. by the way, there was one thing i agreed with one of the speakers who spoke an hour ago. data -- a lot of people say data 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 really mean anything. that doesn't have a lot of value. the value is created when you extract valuable, useful information out of this set of the data. that's where data analytics comes in. that's where the real value and business value is created. okay? on top of that, there is a service layer. this is the most important and the most valuable layer. this layer makes a decision based on the information collected through all the sensors, wearables, and all these things.

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

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

a task to figure out why we are not seeing -- why we are not seeing an exponential growth of i.o.t. and cps in our world. we see incremental growth. we talk about it. there are a lot of wearables on that. but we don't see the momentum like the cell phone industry injured the last few years. why is that? what it concluded at the time is it's because the i.o.t. and cps landscapes are extremely fragmented. a lot of the technology they are using could or can come from transportation system or personal -- smartphones, for example, or disaster response system. they are all developing these things. do not have a lot of interope

interopposi interopposiinterope interoperability. i'll give an example of what it means by cross sector example. crash-to-care scenario. you have a huge accident pile on the highway and what happens? somebody's going to call 911. ambulances are going to come. they're going to start calling hospitals around. who has the best available? who has the right surgeon and doctors available? if they're not available, you've 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 cell phone and call hospitals. you use it as a command center. this was an example in boston marathon incident a few years ago, and they did a heroic job to take care of the situation with the given limitations and systems. but we believe we could have done better if we had a system that could coordinate and orchestrate and also connect these different emergency response systems, hospital triage systems, availability of hospital resources, and availability of the traffic, ambulances. obviously, they want to get there faster. can traffic system handle this kind of -- if you had something like this, cross sectoral collaboration, we could have done better. so a few years ago, we created a program called the smart america challenge. it was a collaboration practical

to bring industry, academia, government agencies all together to really encourage a collaboration with very specific goals like saving lives, creating more jobs, creating more businesses, and improving the economy. that was a very successful program. and after that, nist basically took it and -- we call it institutionalized -- i'm still trying to figure out the government terms. i'm not exactly used to that, but i'm trying. we tried to institutionalized and create a program. we want to create economies of scale. without economies of scale, it

will be just science fair going forward. it is just going to be bits and pieces here and there. we want to create replicable cities, scales, and models. we wanted to create teams and create measurable impacts. currently, we have about 100 teams in total in over 120 cities all around the world participating. over 300 companies and universities and nonprofits are participating. so what do we do? this is what it does. this is actually a smart city capacity building program, but health care is an extremely important part of it. if you go to any city and you go to the health care department or the envirnt