. . >> how is c-span funded? >> by donations.

federal funds, grant funds. >> maybe private contributions. >> honestly, i don't know. >> i would say from commercials. >> advertising. >> something from the government. >> how is c-span funded? 30 years ago, america's cable companies created c-span as a public service a private business initiative, no government mandate, no government money. >> from earlier today, the news conference with president obama, mexican president calderon, and canadian prime minister harper this event took place in guadalajara, mexico. president obama returns from the summit this evening. >> we can now begin the news

conference. the president of mexico is taking the stage now. right honorable prime minister harper, president obama, ladies and gentlemen, representatives of the media, national as well as international. the leaders of the united states, can darks and mexico have completed two fruitful work days for the benefit of our continent. the leaders share the vision for the regional community that is safe, secure, and competitive, that can face successfully the challenges of the present and the future and pointing out that in an age marked by globalization, the challenges can only be overcome jointly. thus the importance of keeping the dialogue, trust, and

cooperation amongst our three countries. americans, canadian, and mexicans have reiterated that the values upon which our societies are founded, our commock -- are democracy, freedom, justice and the respect of human rights. our three nations have reiterated our decision to combat organized crime in order to bring about more security to our communities. the struggles we have led in mexico for the rule of law and the security of our mexican people forces us to stop a traffic of weapons and of money that go from north to south that strengthen and nourish organized crime gangs. the notion of responsibility, accountability, the exchange of information, and the building of our institutions should be

the guidelines for our cooperation. in this international crisis context, the three states that make up the north american region have to take the leadership and foster the necessary measures to recover our economic growth. in our task, we have had to implement countercyclical measures that have been put into action and in a coordinated manner, we can stabilize our economies and bring about trustworthyness and certainty in regard to the future of the global economy. it is also necessary to build our financial international institutions such as the world funds, the international monetary funds, which are fundamental to guarantee the financial resources in the case of latin america, the support

that will enable us to recapitalize inter-american bank for development will be the best action and commitment in regard to the poor countries in the region in -- on behalf of the north american countries. i am certain that at the next g-20 meeting that shall take place in pittsburgh, the united states, will be a great opportunity to build the necessary agreements to reform the organizations that are key in the recovery of our economies and our reprisal. i thank president obama for fostering this meeting in pittsburgh and the united states, mexico, and canada have to restart our agreements. we recognize that it is essential to abide by nafta and to resolve the pending topics that impede us to reach greater regional competitiveness and it

is important to see how we are going to fulfill our commitment in regard to the environment and in regard to our labor domains linked to the commercial agreement, the trade agreement we have amongst our country. i am convinced that only by tapping the investments, labor, technologies and natural resources, we shall be successful in the world that is ferociously competing. at this time, we have reached important agreements such as boosting decentralization of regulations and certifications of our products as well as the sanitary procedures and -- sanitary procedures that can be simplified as well as increasing the economic competitiveness in our region. the objective is to have in

secure and efficient conditions these procedures to be implemented with no bureaucratic or far-fetched red tape in our offices and this will diminish -- decrease the prices for the staples and food and improve the competitiveness of our economies. on the other hand, the bilateral aspects, mexico and the united states will launch modernization initiatives at our common borders with determined termed in order to promote the regional competitiveness actions mexico commends and is pleased to say that we are going to inaugurate the first international bridge that is currently being built after so many years between the united states and mexico. the united states, mexico, and canada have coincided in the

importance to face the repercussions of climatic change, the cost is high but the prige we shall pay for lack of action cannot possibly be calculated. we coincide we have to foster the global agreement in copenhagen and the instrumentation for a green fund to finance and support mitigation and adaptation actions in regard to the global scale of the climatic change. we need to make congress in regard to clean energies and technologies as well as the development of our carbon bonus market in order to have a regional market. north america has to be recognized as a responsible region and must set the example for the world in terms of environmental cooperation amongst countries with the level -- with different levels of development. cooperation and solidarity amongst the north american

region must prevail at all moments, thus it was demonstrated last april when our three countries faced the new virus, h1n1 and working together, we showed our highest expressions of responsibility, accountability, and transparency and because we alerted timely the other regions in the hemisphere, they had the opportunity to implement preventive measures to abate the propagation of the virus and avoid its lethal repercussions. h1n1 as we know will be back this winter. we are getting prepared, every country, to face in a responsible manner the contingency and lower its impabblingt for our people. prime minister, mr. president, at this time, the

representatives of canada, mexico, and the united states have had an open dialogue as befits countries that share conditions and have been able to found a successful society based on brotherly and responsible relationships. we believe in the north american region that is united, prosperous, and wealthy that is able to build a better future for the forthcoming generation. i want to give the floor now to mr. steven harper, prime minister of canada. >> thank you, mr. president, we agreed on three issues. they fitted into three broad category the economy, north american health and security, and energy, environment, and climate change.

on the economy because of canada's strong record of financial regulation and fiscal management, we provided an informed voice at these meetings. as we approached the g-20 summit in pittsburgh we continue to emphasize the country's most strengthen financial regulations and institutions, continue to implement timely stimulus and maintain open markets to resist protectionism. on north american health and security we talked about our shared and effective response thus far to h1n1. it is a cross-border threat to all of us. the excellent cooperation among these -- our three countries was effective in helping to mag the -- manage the initial outbreak and we'll continue to cooperate. in security, we recognize the commitment of president calderon in taking on drug traffickers. we are supporting these efforts as it is a shared challenge for all of us in north america.

also on international peace and security, canada supports ongoing o.a.s. efforts to find a peaceful resolution to the crisis in hon cure rass. we must restore both democratic governments and the rule of law. i just about missed energy and climate change. given the integrated nature of our economy we did talk at some length about the importance of working together on a north american approach to climate change and also on doing our best to ensure that out of copenhagen going forward, we reach an effective and genuinely international new world protocol on greenhouse gas emissions. to conclude, can dark the united states, and mexico are good neighbors and good friends. as sovereign countries in a modern world, we are independent and interdependent. i am looking forward to seeing president calderon and president obama at the g-20 and

looking forward to hosting both of you next year at canada's summit in our great country. thank you. >> good morning. buenos dias. i want to thank my great friend, president calderon, for his hospitality and for hosting us at this important summit, as well as my good friend, prime minister stephen harper and i want to thank the people of guadalajara and mexico for the incredible warmth they've shown us on this, my second trip to mexico as president. here in mexico, the word is juntos. in canada, it's -- -- but no

matter how you say it, we come together because of the challenge and opportunities we'll be facing together. like our magnificent surroundings today, this could not be a more fitting venue. here in guadalajara, we see the richness of mexico's heritage, its arts, architecture, vitality, and culture, and we also see all the possibilities of mexico's future, this innovation, high--- high-tech industries, and entrepreneurship that make this one of the most dynamic cities in our hemisphere. we also see our continent coming together, canadians, mexicans -- mexicans, americans, each bringing their unique traditions, each bound by mutual respect. in the 21st century, north america is defined not simply by our borders, but by our bonds. that is a spirit that defines the very productive summit we had here today.

first we agreed we had to work together to restore our common prosperity. the global recession has cost jobs and hurt families from toronto to toledo doe to tijuana. we renewed our agreement to work together, we agreed to continue to take aggressive, coordinated action to restore economic growth and create jobs for our workers, including workers in the north american auto industry. because so much of our common prosperity depends on trade, billions of dollars bort of trade every day, we reaffirm the need to protectionist. we are among each other's largest trading partners as we work together toward lasting prosperity we need to expand

that trade, not restrict it. i would note that our common prosperity also depends on orderly, legal migration. all three of our nations have been enriched by our ties with family and community. i think of my own brother-in-law who is canadian, i think of the many mexican americans from jalisco who found homes in los angeles, texas, and my hometown of chicago. at the same time, americans, mexicans, and canadians expect their borders to be safe and secure. that's why my administration will continue to work to fix our immigration system in a way that's in keeping with being a nation of laws and a nation of immigrants. because our future prosperity also depends on clean energy economies, we invest in renewable energy and clean jobs. we recommitted ourselves to the historic goals announced last month in italy. countries like the united states and canada will take the

lead in 2050 and work with other nations to cut global emissions in half. indeed we made progress toward the concrete goals that will be negotiated at the copenhagen climate change summit in the summer. i want to commend mexico for curbing greenhouse gas emissions and president calderon for his proposals to help developing couldn'tries build clean, sustainable economies. we reiterated our commitment to the safety of our people. in regards to the h1n1 pandemic, we have worked closely, collaboratively and responsibly. we will continue to make all necessary pro pre-cautions to prepare for the upcoming flu system and prefair -- protect the health of our people. this challenge transcends borders and is must our response. we must also continue to address the threat to our

common security from drug cartels that cause so much violence and death. i heartly commend president calderon and his government for their courage in taking on these cartels and the president reaffirmed his commitment to transparency, accountability, and human rights as they wage this necessary but difficult fight. the united states will remain a full partner in this effort. we will work to make sure mexico has the support it needs to dishasn'tle and defeat the cartels and the united states will also meet its responsibilities by continuing our efforts to reduce the demand for drugs and continuing to strengthen the security of our shared border, not only to protect the american people but also to stem the illegal, southbound flow of guns and cash that promote this violence. third, we reiterate our commitments to peace, democracy and human rights.

we talked about honduras. we remain united on this issue. he remains the president, and democratic order must be restored. we will continue to work with others, especially the organization of american states to achieve a negotiated and peaceful solution. finally, we pledge to continue these efforts. i look forward to welcoming prime minister harper in september. i look forward to welcoming both my friends at the g-20 in pittsburgh where i hope to reciprocate president calderon's hospitality, our progress today is a reminder that no nation can meet the challenges of our time on our own. our common aspiration can only be achieved if we work together and that's what the nearly half billion people in north america expect from us. so that's what we will do. thank you very much.

[speaking spanish] >> good afternoon. there are certain questions about violation of human rights here in mexico and all these problems, fighting drug trafficking, are you going to certify mexico and how can we move forward with the initiative? we've also been concerned about any attempt against felipe calderon's life. we know about certain threats and his security that prevails. this, of course, is certainly related to your country. we're concerned about the visa problem, too, but what comments would you have regarding these questions?

[speaking spanish] >> what are your concerns regarding this. we'd also nike -- like to know if mexico will be certified and if you'll help in applying resources for the initiative. we've also heard about aterpts against the life of president felipe calderon. do you have knowledge of this? we're also concerned about national security, about visas, we'd like to know is there any possibility that you might turn this around that we might not have any limit on visas? >> i'll just address the first two questions that seem to

apply to the united states. number one, we have been very supportive of the initiative and we will continue to be supportive. we have already seen resources transferred, equipment transferred, in order to help president calderon in what is a very courageous effort to deal with a drug cartel, a set of drug cartels that are not only resulting in extraordinary violence to the people of mexico, but are also undermining institutions like the police and the jew dish care system that, unless stopped, will be damaging to the country. now with respect to the conduct of this battle against the cartels, you know, i have great confidence in president calderon's administration. applying the law enforcement techniques that are necessary to curb the power of the

cartels, but doing so in a way that's consistent with human rights. we discussed this in our bilateral meeting and i am confidence that as the national police are trained, as the coordination between the military and he call police officials is improved, there is going to be increased transparency and accountability and that human rights will be observed. the biggest, by far, violators of human rights right now are the cartels themselves that are kidnapping people, extorting people, encouraging corruption in these regions. that's what needs to be stopped, that's what president calderon committed to doing and that's what i committed to helping president calderon accomplish, as long as he's president of mexico. >> we'll continue.

>> on the question of visas, it's important to understand the imposition of visa is due to one thing and one thing only, that is the dramatic rise we have seen over the last few years, and this year in particular, in the number -- in the number of bogus refugee claims being made from mexico into canada. it's important to understand that the decision, first of all, has nothing to do with the actions of the mexican government. the mexican government has cooperated with us in efforts to stem this particular problem, to limit this particular problem, and continues to work with us in ways we might reverse it. the underlying problem as i said to president calderon and others, the underlying problem is in the canadian refugee log. it is far too easy in canada to make a bogus refugee claim to into the country. we have to change that.

it is unfair to those who are legitimate refugees and to the hundreds of thousands of people working through our immigration system to become immigrants to our country. as i say, we'll continue to work with mexican authorities to try and limit this problem, but in the absence of legislative change, it is very difficult for our governments to control this, other than through the imposition of visa. it is the only tool available to us right now so we need additional tools from our parliament to stem the flow of bogus refugee claimants and also to have additional tools to deal with this kind of problem. >> alex panetta, canadian press. >> the topics which were very important to us, first of all,

my government has an absolute and categorical commitment with human rights. the struggle, the battle we are fighting against organized crime is precisely to preserve the human rights of the meck can people, rights to safety, security, personal safety, integrity and the right to have a safe family. the right to work without being really molested or perturbed and the struggle for the security, the safety of the mexican people, obviously we have a strong commitment to protect human rights of everybody, the victims and even the criminals themselves and this is how it has been, this is how it will continue to be and this is how the federal police will act, the attorneys general and armed forces will act. all in all of these cases, there have been -- there has been a scrupulous effort to protect human rights in all

cases. anyone who says the contrary certainly would have to prove this. any case, just one case, where the proper authority has not acted in a correct way, that the competent authorities have not punished anyone who has abused their authority. whether they be police officers, soldiers or anyone else. we have a clear commitment with human rights. we have met this commitment, and we will continue to do so. not because of any money that might come or come through, through the initiative or what's set in the u.s. congress, because we have the strong commitment to human rights and i certainly in a personal sense for several decades now and i have alms had this commitment -- and i have always had this commitment, i have details about what you have pointed out but in any case this won't be the first or last occasion on which we might

hear something about an attempt against my personal -- about my life, my person, but once again, the government just can't stop, it can't be disturbed. we know that we are destroying the criminal organizations, we're hitting them hard, hitting at the heart of the organizations. we're making them back away. and we know, they know, that we're not only taking an initiative in the struggle against crime, but we are actually being able to protect, defend our country better as time goes by. this is not a type of vengeance, of getting back at anyone, but we want to make sure that mexico is a safe place to live in, that we will be able to move forward in this one, we're not talking just about this organization, but our basic objective is to

provide security, safety for the mexican people, this is something -- this is something the mexican people are entitled to, they can go out to play, go to school, they can make progress and fulfill their aspirations that mexico be a free country freerk of delinquency, free of violence, that mexico be a safe country, and we're not going to be intimidated, nor will they put a stop to you are efforts. i hope mexican society recognizes all the efforts we're making along these lines, the police force who have been victims of attempts and cowardly acts by the criminals, all the efforts carried out by mexican marines, by soldiers, different attorneys general's offices, because we are committed to this ideal to have a safe mexico a safe country. these are values that we believe in and they're certainly stronger than any threat that could be made against us about anything

whatsoever. so once again, we have had dialogues with prime minister harper on several different occasions, as we did on this occasion, about the summit, and the matter of visas for mexican visitors. we've talked openly, frankly, and certainly mexico certainly feels very bad about this decision, about this rejection, even though, of course,s the privilege of the canadian government to stipulate this, but it gets in the way of a good relationship of what prime minister harper and i are doing to have good relations between the two countries. the explanation that prime minister harper mentioned, it is a problem, with the bogus refugee claim problem, this has led to an abuse of the system. we're going to try to work together, collaborate together, we're doing this here in mexico to try to do away with the

underlying causes of this abuse regarding the general system for r.v.ing refugees in canada. -- for revving refugees in canada. -- for receiving refugees in canada. i certainly have the obligation of assuring that a specific topic on the bilateral agenda not deter reaching our full potential of other matters on the agenda. once again, here lies the great opportunity in this particular area of economic complimentary -- complementry of the three countries' economy, that is take our whole region up to a higher state of competitiveness. these are the lines we've been working along, i think we have been making great strides in a sense, and we certainly will continue to work along these lines. i'd like to open this up.

>> i hope you forgive me for this being a long question, we only get one question each. this is primarily for president obama. >> use the microphone, please. >> i would appreciate if the prime minister could answer in french as well. buy american causes considerable concern outside the united states, i wonder what you discussed about it, what power you have to rescind the power and if you intend to. on a not completely related topic, health care has been an issue of debate in your country, canadians have lock -- canadiens have looked on -- canadians have looked on with surprise, i'd like to wonder if -- i'd like to ask if you see

any parts of the canadian health care system that are worth emulating. >> as to the buy american issue, the prime minister raise ths issue every time we see each other. i think it's important to note that we have not seen sweeping steps toward protectionism. there was a very particular provision in our recovery package, our stimulus package, that did not extend beyond that, it was w.t.o. compliant, it was not something that i thought was necessary, but it was introduced at a time when we had a very severe economic situation and it was important for us to act quickly. and not get bogged down in

debates around this particular provision. prime minister harper and i have discussed this and there may be mechanisms whereby states and local jurisdictions can work with the provinces to allow for cross-border procurement packages that expands the trading relationship, but i do think it's important to keep this in perspective. this in no way has endangered the billions of dollars of trade taking place between our two countries. it's not a general provision, but it was restricted to a very particular aspect of our recovery package. with respect to the health care debate, we are having a vigorous debate in the united states and i think that's a healthy thing. the reason it's necessary is because we are on a currently unsustainable path. we spend far more per person on health care than any nation on earth.

the -- our outcomes in terms of various measures of well being don't rank up at the top. we're not doing better than a lot of other country -- than a lot of other developed countries that are spending much less per person. individual families are being bankrupted because of the lack of insurance. we've got 46 million or 47 million people without health insurance in our country and for those who do have health insurance, they are always at risk of private insurers eliminating their insurance because of a pre-existing condition or because of -- if they lose a job or have changed jobs. so the final aspect of it is that our health care inflation is going up so rapidly that our federal budget simply can't sustain it. nor can businesses that are increasingly having to make

decisions whether they hire more workers or eliminate health care. whether they stop providing kverage or force more costs onto their workers. the whole system is not working well. how do we change it? when it's 1/6 of the u.s. economy, there will be a lot of opinions. congress has moved toward and we are closer to achieving a serious health reform package than we have been in the last 40 to 50 years. but there continues to be a vigorous debate. i've said the canadian model works for canada, it would not work for the united states, simply because we've evolved differently. we have an employer-based system a private-based health care system that stands side by side with medicare and medicaid and our veterans administration health care system. so we've got to develop a uniquely american approach to this problem. this, by the way is a problem

that all countries are going to have to deal with at some level because if medical inflation continues at the pace that it's going, everybody's budgets are going to be put under severe strain. what we're trying to do is make sure we have a sensible plan that provides coverage for everybody, that continues the role of the private marketplace, but provides people who don't have health insurance or have fallen through the cracks in the private marketplace a realistic and meaningful option. we've got to do it in a way that change ours delivery system so we're not engaged in the kind of wasteful, inefficient medical spending that's so costly to us. so i suspect that we're going to have continued vigorous debate. i suspect that you canadians will continue to get dragged in by those who oppose reform, even though i've said nothing about canadian health care reform. i don't find canadians

particularly scary, but i guess some of the opent -- opponents of reform think they make good bookymen. -- bogeymen. i suspect once we get into the fall and people look at the actual legislation being proposed, that more sensible and reasoned argumented will emerge and we'll get this passed. sorry to take so long on the question. [speaking french]

[speaking french] >> on buy american, we did have a good discussion, as president obama said. i'm happy to see our provinces and the federal government have recently come to an agreement to work collectively on this matter, which is largely, actually, within their jurisdiction since this concerns some national procurement. our respective trade ministers have been talk, officials are talking, we expect -- i anticipate that president obama and i will be discussing this

at greater length in upcoming meetings. on the american health care debate, on the debate over the system of health care, we know, as you know well, canadians support their own health care system. as for the rest of this question, the only answer is, this is an american debate and the responsibility of the provinces. >> ginger thompson. >> i'd like to start with president obama, please. given the fight you're having to wage for health care, i wonder if you can tell us what you think the prospects are for immigration reform, for comprehensive immigration reform which you said is your goal, and whether you think the blows you're taking now on health care, and that the democrats are likely to take around the mid term elections,

will make it hard if not impossible to achieve comprehensive immigration reform in this term, and who what you told president calderon about that? president calderon, i'd like to hear a little bit about your thoughts on honduras. there have been some in latin america who have said that the united states has not acted strongly enough to return the hon duran president to power. i wonder if you can talk a little bit about how you feel about what the united states could be doing or should be doing to restore democratic order in honduras and prime minister, harp -- prime minister harper, a few months ago, the homeland security secretary of the united states went to canada, or at least aggravated canadian sensibilities when she compared the canadian border to the mexican border and i wonder what you think about that and how you feel about the united

states using some of the enforcement strategies adopted on the southern border in the north? thank you. >> that's all? >> that's all, mr. president. >> well, first of all, ginger, i don't know if you're doing some prognosticating about the outcome of the mid term elections, which are over a year away, i anticipate we'll do just fine. and i think when all is said on health care reform, the american people are going to be glad that we acted to change an unsustainable system so that more people have coverage, we're bending the cost curve and we're getting insurance reform so that people don't get dropped because of pre-existing conditions or other issues. so understand, though, i'm not

acting based on short-term political calculations. i'm looking at what's best for the country, long-term. if i've been -- if i'd been making short-term political calculations, i wouldn't be standing here as president because nobody calculated i could win the presidency. with respect to immigration reform, i continue to believe that's in the long-term interest of the united states. we have a broken immigration system. nobody denies it. and if we continue on the path we're on, we'll continue to have tensions with our mexican neighbors. we'll continue to have people crossing the borders in a way that is dangerous for them, unfair for those aplaying legally to im-- applying legally to immigrate, we'll continue to have employers exploiting workers because they're not within a legal system and oftentimes are receiving less than minimum

wage, don't have overtime or are being abused in other fashions. that's going to depress u.s. wages. it's causing ongoing tensions inside the united states. it's not fair and it's not right. we're going to change it. now, i've got a lot on my plate and it's very important for us to sequence these big initiatives in a way where they don't all just crash at the same time. what we've said is in the fall when we come back, we're going to complete health care reform. we still have to act on energy legislation that has passed the house but the senate, i'm sure, is going to have its own ideas about how it wants to approach it. we still have financial regulatory reform that has to get done because we don't want a situation in which irresponsible actions in the global financial markets can precip kate another crisis. that's a pretty big stack of

bills. what we've been able to do is begin meeting with both democrats and republicans from the house and the senate, secretary napolitano is coordinating these discussions and i would anticipate that before the year is out, we'll have draft legislation along with sponsors, potentially, in the house and senate, who are ready to move this forward and when we come back next year that we should be in a position to start acting. now, am i going to be able to snap my fingers and get this done? no. this is going to be difficult, it's going to require bipartisan cooperation, there are going to be demagogues out there who try to suggest that any form of pathway for legalization, for those who are already in the united states, is unacceptable and those are fights that i'd have to have if my poll numbers are at 70% or if my poll numbers are at 40%. that's just the nature of the

u.s. immigration debate. but ultimately, i think the american people want fairness and we can create a system in which you have strong border security, we have an orderly process for people to come in, but we're also giving an opportunity for those who are already in the united states to be able to achieve a pathway to citizenship so they don't have to live in the shadows and their children and their grandchildren can have a full participation in the united states. i'm confident we can get it done. oh, excuse me, i know this wasn't directed at me, but i want to make one quick point on honduras because you repeated something that i've heard before. the same critics who say that the united states has not intervened enough in honduras, are the same people who say

we're always intervening and we need to get out of latin america. you can't have it both ways. we have been very clear in our belief that the president was removed from office illegally, that it was a coup, and he should return. we have cooperated with all international bodies in sending that message. if these critics think it's appropriate for us to suddenly act in ways that in every other context they consider inappropriate, then i think what that indicates is that maybe there's some hypocrisy involved in their approach to u.s.-latin america relations

that certainly is not going to gut my administration's policies. [speaking spanish] >> many of the people who work in the united states who live in the shadow, live in the state or come from jalisco, the state. these are people who have migrated to build a better future for their families. all of them, or most of them, have enormously contributed to the american society and the american economy and it is unthinkable to see that the u.s., the main power, the main economic power in the world, disvalues the contribution of mexican laborers and workers. this is not only a good will

statement. during our meeting, we handed the delegation the benefits of north america and why the mexican population represents in terms of the population of the united states. the only way to have sustained progress throughout the north american region, especially, is for allowing for the natural economic processes so immigration can happen, this implies the labor mobility that cannot be determined by mandate or decree. this is what we have underscored with president obama during this meet to keep on invoking the protection for the mexican laborers, whatever their migration conditions are in the united states and our highest commitment to the way president obama has tackled this migration issue. now aside from defending the rights of the mexican laborers

in the united states, one day, instead of the mexican people having to leave their country because they're hungry, we need an economic scheme where we have great investments coming from the u.s., hailing from canada, and opening here the labor opportunities that the mexicans so need. i think president barack obama has responded to the topic, or to the issue on honduras. what we have discussed and agreed is what needs to be done . to build the international action that was been taken in order to re-establish democracy in honduras, to strengthen the o.a.s. and the group that's going to meet, to build the mediation actions that oscar arias, the president of costa rica, is carrying out in order to re-establish the

constitutional law in honduras. this is not about a person or another. this is not about the president of honduras himself, per se, it is about the constitutional and democratic lives that ought to be defended in regards to the international legal framework we have all agreed upon and one more expression, i coincide in the contradiction highlighted by president obama. those who have rejected or have argued about the intervention of the united states in the region, are those who now are claiming for the determination or the intervention of the u.s. in the region no matter how legal this action might be. so we have to resort to international law and international instances beyond the intervention of one single state or even more. the intervention of one single person to resolve such a dispute and such an issue.

this is a path to be taken. today we congratulate ourselves that president obama is leading the administration of the united states but in the past that happened, but in the future we don't know who might be president next. i am not of those who share the idea that the u.s. are elected as the ultimate judge and the ultimate sovereign resolvers through the intermediation of the affairs in our country yes, we have to have -- our countries. yes, we have to open the paths to organizations, for groups we have formed such as rio group, groups that are friends of north america, countries that befriend honduras, that befriend central america, that befriend guatemala. these countries must act on our own account, but in observance of the international law and the rules we have settled

ourselves. we have to perform a group of friends of honduras that through -- with the help of oscar arias and with the help of the o.a.s. and their forthcoming action. >> just briefly, minister van lauden and secretary napolitano and other initials -- officials have been meeting on the question of our shared border, i think we have good cooperation in that regard. there's always work to be done. let me be clear, from the canadian perspective, we look at our border as a line between the two closest countries on earth. we have the largest trading relationship of any two countries on earth, but we also share security concerns. i've said repeatedly, i'll say again, there's no such thing as

a threat to the united states which is not a threat to the security of canada. that's why canada has been a steadfast ally of the united states, nafta, and norad for many, many years. we want to address the same security issues the united states wants to address and we want to do so in a way that doesn't impede commerce and doesn't impede the great social interaction which has made our two countries so close over the decades. i'm just going to also weigh in a little bit. as a friend of the united states, on the question posed to president obama. if i were an american, i would be really fed up with this kind of hypocrisy. the united states is accused of meddling, except when it's accused of not meddling. and the same types of -- the same types who are demanding the united states somehow intervene in honduras, the same

type of people who would -- who would condemn long standing cooperation between colombia and the united states, which is being done for he jate in the security and drug traffic reasons that are in the interests of all the countries of this hemisphere. mexico and canada are involved in the mediation effort l efforts in supporting the mediation efforts of president areas -- areas. i think the united states has forcefully articulated its concerns and its outcomes in that regard and has been supportive of those of us working in the multilateral process to deal with this serious issue in the hemisphere. so, you know, i think that's precisely what we want to see from the united states is the united states that leads on issues of values but is very supportive of multilateral attempts to deal with

challenges that we all face. >> thank you. >> thank you. >> thank you. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> tonight on c-span a look at efforts to change the nation's health care system. we'll begin we the white house roundtable on health care. after that, a forum from the alliance for health reform, discussing legislation on capitol hill and the health care system in massachusetts. later keith epstein of "business week" on his recent cover article on why health insurers are winning. >> now health officials from government and the private sector discuss the -- discuss

proposed changes to the health care system. they look at a range of topics touching on primary physician care, medicare, medicaid and government-sponsored health insurance. hosted by the white house, this is about 90 minutes. >> let's get started. i appreciate you all being here in august to talk about health care. a lot of people may be watching at home. as you know, we're committed, and president obama is committed to enacting health reform this year. [inaudible] primary care is

really important. right now, we all know that high costs makes it difficult for patients to afford adequate insurance and comply with treatment recommendations and there's one thing we know for sure, quality is uneven across the system. we need to do something about that because too many patients don't receive the recommended care. so our goal and the thing that many of you have been working toward, vermont, good to see you again, and other places around the country is to try to improve that and address the challenges we want to working with congress and all of you, including physicians and state health leaders who have been engaged in some of these reforms. this is going to require changing the way we deliver health care so we're really gratified that some of you have already been engaged in that difficult work.

we need to focus on improving the quality of outcomes, making sure we're providing better care, coordnating care for patients with chronic diseases. all those are things that primary care has a critical role to play in doing and driving the transformation of our delivery system we know we need. today we've gathered experts in the field and some of you who have been working to do this around the country to discuss only advanced models of primary care that can meet the challenges of our health care system. we believe that the reform that we're talking about offered a major opportunity to improve the quality and coordination of care leading to improved patient health and experience, but also low in cost and i'm looking forward to hearing what some of you have to say about your experience in doing that. we're joined by health care leaders who have been developing advanced models of primary care that address these challenges. we have representatives from state medicaid programs, health

plans, integrated delivery systems and physician societies. we're also joined by academic experts and we appreciate your willingness to come and share your perspectives and expertise on how to improve and expand these advanced primary care models. we have people here from all over the country and people who traveled a long way and we appreciate your taking the time to do that. .

>> i'm barbara smith, special counsel in the office of health reform, nhhf. >> i'm ibm's general manager for global healthcare and life sciences responsibility. >> i'm dan fields, i work at the national economic council on healthcare. >> bob phillips, director of the robert graham center, part of the american academy of family physicians. >> i'm the policy director for the medicare program. >> i'm ken thorpe, professor of public policy at emory university and the executive director of partnership of iconic disease. >> -- chief of staff, the first lady -- also part of the healthcare reform team from the white house counsel's office. >> my name is elizabeth session and i work on the national economic council on healthcare policy. >> i'm kevin grumback and i

partner -- >> i'm mark dug began senior economist at the -- >> i'm phyllis torda, chief executive for the national committee for. >> paul grundy, director of healthcare transformation forfom corporation -- representing about 400,000 physicians on primary care and most of the fortune 500 to really drive transformation and change in the covenant in the way we buy care and deliver care around a model of care, patient center primary care. >> i'm john tucker. c.e.o. of the american -- an internist. >> i'm executive director of the national association of public hospitals and healthcare systems and will emphasize the health systems part in this meeting. >> i'm a family practitioner.

previously -- [indiscernible] >> craig jones, i'm the director for the vermont blueprint for health and a pediatrician as well. >> and i'm michael soman, a family physician who practiced for 17 years at group health -- now i'm the president of a medical group and medical director of the owned and operated delivery system. >> barbara walters, senior medical director at dartmouth hitchcock chicago and -- [indiscernible] and here today with -- [indiscernible] >> i'm dick salmon, family physician and national medical director for performance improvement for significant that health. >> my name is sue williamson, deputy director of the colorado department of healthcare partnership and financing. our agency administers our public health insurance programs like medicaid and our s-chip

program. >> i'm david dorr, a practicing inearnist and medical -- at oregon health and sciences university. ly explain that. i work on a model called care management plus. >> i'm allen dobson, a family physician with carolina healthcare system now. i'm the chair of the community care of north carolina and formerly the medicaid director and secretary of health. >> and my name is bob koch, i work with the national economic council. i want to thank everybody for coming. we are thrilled to have a tremendous cross-section of innovative practices and experts who think about primary care. i want to take a few minutes and talk to you a bit about the opportunity to do advanced primary care and frame a discussion that we'll have going forward. if you, i would like to do that. >> nancy-ann said we are thrilled that this year we will

be talking about healthcare reform in ways that reduces the cost and cost growth for americans families and businesses that improve the quality of care and expands access and choice to millions of people. today's discussion is going to be all about improving the quality of car. around the table we have folks who have done amazing things to improve the way patients receive care and -- it is only going to accelerate the improvement in care. i want to talk a bit about the changes in quality that we foresee coming which many of you embody in the delivery system. the first is we're going to address quality. a theme we're going to hear today is all about ordering quality of care and think about ways we can align the incentives to practice in ways like you have. -- it is not done because of costs. the we're going to make sure that health plans cover that and make that accessible to everybody. because that actually reduces costs and improve quality and is the right thing to do for shoe.

coordination is going to be something that all of you have thought a lot about and going to think a lot about how to coordinate care with such that patients who have multiple diseases get the right care for their combination of diseases and each disease and that the care team will know who's in charge and who's doing what and what need to happen. there's a lot that goes into. that that has to be improved. making sure the patients get the right clinically recommended treatment. too often we fall short on delivering evidence-based care. there are lots of reasons why that may happen. but your practices have all come up with ways tone sure that evidence-based care benefits more often the patients and figures out when it's not happening to remedy that and get patients back on the right treatments. -- is something that's chronic in our healthcare system. and you've all thought through ways of organizing the care to avoid duplication and even thicks that are unnecessary and

those that are not done. and finally the connection of community. we have a system of clumsy handoffs between hospitals, specialists, primary practices, community for families and patients. clearly it's costly. again today going to talk about ways to ensure that community and families and patients are much more likely to be informed and cooperative in the care. and finally, reform will expand access to millions of people who don't have access today. we talk about primary care today because primary care is something that too often isn't in place for enough patients. primary care, what we refer to when we say primary care, what what we mean is a doctor and a practice and homefully a carry team who is responsible for ensuring that a patient working with them gets the proper care. that a patient knows who to call, that they call them back, that if you have questions you have somebody who can answer, you have concerns about accessing specialists or what to do that there's a practice that

actually serves those needs for you. and many of us in the room experience that, most of you deliver those types of care to your patients. but it's too often not the case. the and so in the care system of the future we will absolutely have a much more robust primary care system that will more like what we talk about today. next i want to point out that around the table is incredible impact. we have seven systems who have all taken primary care in different ways but all with similarly impressive results. we're going to hear stories today about how north carolina saved $400 million already taking better care of medicare patients. -- across a really set of patients who are different and complicated in different ways than the population that allen is going to talk about. how colorado has really improved pediatric care and had remarkable improvement in compliance in state metrics. how group health has very

quickly avoided a lot of emergency room says visits that would have led to both -- outcomes, frustration and expense for families and how geisinger has -- we have really compelling stories today. what's amazing about these stories is we have talked to these groups andland more about them is it's things that can be done widely in many places. these are not limited examples. these are examples that all could be scaled. in today's discussion we'll talk some about how we can actually scale these so more patients get more of the benefit we're going to hear about today. as we go through, there are going to be 2004 elements. so i said there are many difference. there are four things that are common to all these practices. the first is the notion of carry coordination. so it's not left to chance what happens after a patient see. whether there's a followup process to ensure that whatever has to happen patients are reminded, physicians are

reminded. it involves not just information technology but teams to take care of patient. because there's no one person in charge, there's jobs that need to be done by a full team. there's a much more patient engagement in these practices than in a typical practice. so patients know what to do. they're followed up in some cases so the patients are rewarded for doing the right thing. but they're much more education that goes into the care of patients in these practices than in many around the country. easier access. so in these practices when you call them they answer. and you're likely to hear a phone call answered on the first phone call. that's not typical in many practices. so they've come up with ways to make it much easier to interact. in some cases the practices are open nights and weekends, there's alternatives to emergency rooms and it's much much simpler to communicate, sometimes by e-mail and other ways to make it easy for patients. and finally they're data driven. so each of these practices

utilizes information technology to ensure the practices are reminded which patients are high risk, that the interventions can be taken before -- need age-appropriate screenings so if the appointment is not scheduled it's scheduled and happens. so we're going to hear a lot about how information technology makes care better. so i'm thrilled that we're going to get these stories and that there are similarities but also tailoring that's happened in each of these practices that it leads to better care for the patients. allen is going to go first. in the interest of having a spirited round table discussion we're going try to be disciplined about five minutes. we're going to hold up a sign that says one minute warning. and i have to cut you off when you go over which makes me very anxious. so i'm hoping we'll stick to that. because the discussion you know about your practices more than others. so we don't want to go into great detail but talk about what you did and what happened and all of you have data to share in that regard. i'm going to have allen lead off. we'll hold the questions

untilled end and then we can use the round table for questions. >> i appreciate being here and talking about primary care in north carolina. it clearly is now time for reform. and we really must -- to be economically sustainable we have to overhaul a fragmented system. and i think the first must be an investment in primary care. and i think the values and principles outlined in the joint principles of patient-centered primary care is outlined is a pretty good first fundamental step for reform. community care is an example of the value of just such an investment. we started about 10 years ago with this project. community care is a public-private partnership between the state of north carolina and 14 not for profit networks that are comprised of the majority of the local healthcare providers in the state. and it's built around primary care. it also includes all the other physicians, local healthcare

providers and in particular our hospitals, our academic medical centers, public hospital systems, health departments, social services and other safety net organizations. this partnership delivers the patients that are primary care to medicaid and s-chip recipients and other low income adults and children in our state. and our networks have now grown to over 4500 primary care physicians, the majority of primary care physicians in the state and 1360 locations covering all of north carolina, all 1 hundreds counties and manages a little over 1 million patients. and next slide. and this is what the math looks like of how the providers have self-organized themselves. community care delivers improved quality care to our patients and cost savings to our state using -- primary care physicians serve as a medical home or personal physician for our patients. second, local not for profit

networks decree -- are created as a virtual integrated healthcare system that links the primary care physicians and patients to the rest of the local healthcare system and support agencies. it's like the glue in the communities. these networks provide the needed physician leadership and local collaboration in order to create a local solution to improve care management and quality. this provides a flexible structure that has proved to us to be adaptable in the rural areas as well as our largest areas including our largest academic health systems. third the state funds the primary care physicians through an additional blended monthly fee and also fund the network to provide additional local resources to the patients and the primary care doctors such as case managers, care coordinators, pharmacists, medical directors and some local quality improvement infrastructure to make sure that we improve the care.

this assures that optimal support is provided to patients and the results are achieved locally. community care has demonstrated quality improvement and cost savings and obviously phenomenal growth since it's now statewide. and has documented significant savings exceeding $100 million a year since 2003. and in short, north carolina has successfully managed the cost of its medicaid program mainly through a clinical management strategy rather than just a price reductions and regulatory control mechanism. so community care is now kind of the centerpiece of healthcare strategy in north carolina, is enthusiastically accepted by both patients and providers. again it's a value-added proposition. and it's in the community. legislature has mandated its expansion to s-chip and inclusion of mental health. and community care is now working with c.m.s. on a medicare demo that will allow us to continue to care for the

sickest medicare fully eligible and at risk medicare. we believe north carolina's model serves as an important national model for health reform. local infrastructural work both in urban and rural areas as well as public and private systems. the path for our reform efforts i think can be really informed by a lot of folks around this table and a really high-functioning health system. but the problem is that most of our healthcare delivery system isn't in the system at all. and so i think some of the lessons learned from north carolina show the value of investing in patients in primary care and a road map for organizing local communities regardless of size or quality and improvement of quality. so some of my suggestions for improvement would be making sure we adequately reimburse

p.c.p.'s. a blended payment to support those activities, making sure we have enough primary care doctors to meet the needs of our folks. also aligning -- we were able to align some policy and payment decisions to get certain access in comprehensiveness equation like after hours clinics. we need to fund additional care coordination strategies both at the practice and community level and provide the ability for flexible ability for primary care physicians and other providers to link together outside of a risk model. the big thing we learned was that you have to reinvest the savings to get growth in strengthening local systems and get meaningful and lasting growth. and there's a need for preventative services. and clearly there's a need for technical support for primary care physicians to undergo this transformation, maybe through an ag extension model or model in the local community to support primary care efforts.

appreciate the opportunity to be here and participate in the discussion. >> thank you. david? >> great, thank you. as i said, i am an internist and i practice infomatics as well. we study the way -- i like to do this in the context of a patient. so i'm going to talk about our care management plus pilot that we've done at intermountain healthcare and our subsequent dissemination at oregon health and sciences. gloria is 75, she's seen at mountain. i'll show you her picture with her permission in a little bill. she's active. she says her health is fairly good. she lives at home. she's doing pretty well but she has five chronic conditions that kind of accumulated. diabetes, she had a little bit of depression, she had cardiovascular disease and she's having memory difficulties. and so we know just from that that she'll probably see an average of 13 providers a year. she'll fill 50 prescriptions.

she has 90 times the risk of hospitalization versus somebody with no chronic conditions. and the 5% of medicare patients like her account for about 42% of the costs. and so at intermountain where this was developed these were the patients who really wanted to target in primary care to keep them healthy and at home. and so the model is simple. it's a care manager in a primary care team that has specific health information technology to help them. and we use that to help do care coordination, education, motivation and other tasks. we've seen some successes around hospitalizations reduced, improvement in mortality, improvement in quality and efficiency. so a little bit about the background. we started doing this in 2001. and in seven clinics versus six controls, we basically built this system with the help of a care manager. they saw about 70,000 patients

in those clinics, the care managers saw about 4700. and we compared these seven to six control clinics in cost, quality and utilization. our patient population was really focused on patients like gloria although they could refer whomever they wanted. and we've since in the last few years done dissemination in 75 teams at ohsu. so the model is simple. gloria would be referred by her primary care provider to the care manager, actually usually the care manager comes to the room and joins the visit. and then they work out together what gloria and her family need to stay healthy. and so the care managers receive specific training to do assessment and cocreate a plan, and then they have technology to really back up that plan and make sure it happens reliablely. and so the clinics were very similar to clinics. intermountain is a large integrated delivery network but

they had multiple payers. most of their pay did not come from special pay for performance. a small portion. so the care coordinators did this because the primary care providers in the system thought it was a good idea for satisfaction overall. the care managers saw about 350 active patients on average in the pilot. and the health i.t. really helped them to do care coordination tracking, to never lose track of a population or a patient who's at risk, a person who's at risk. and had a centralized reminder system that had protocols that also had kind of the ongoing task around social and other needs that these patients so often face. so scheduling and access was improved as well as a connection to the community through the i. t. and the evaluations were regular in the program. the health plans initially was done by the medical group, but since then we've worked with several health plans and different payment models which

i'll discuss at the end. and we've been working with federally qualified health centerrers in onation as well as medicaid. so what are the results? i hit them at the beginning. i will discuss them. we reduced hospital admissions 20 to 40% and we improved guide line compliance about the same. we reduced mortality. so the patients in these intervention clinics were living longer. people with multiple chronic conditions are at high risk of an exacerbation of their illness that could lead to death. all of this led to significant savings which led intermountain to double the size of the program in the medical group and per patient what we saw about 640 to $1,650 per patient per year savings. we also saw the clinics were more efficient and people were much happier. the patients and their families called this a life saver. they really felt like they couldn't live without it. and the fizz eggses really felt they could work smarter and the pressure on their primary care

was -- the hamster treadmill that many primary care physicians phil they're on with 20 to 30 visits a day was lessened. the care managers even told us that computer tools were an absolute god send which is obviously near to my heart. [laughter] >> so we really felt like that was successful. and what we've done since nen is rolled this out starting at ohsu at more than 75 clinics across the country. and a lot of what i'm going to say for the summary is really going to be focused on what those clinics told us. so next slide. first of all we found that care manager role was essential. most of our dissemination clinics had a thursday but didn't have a care manager. we found nurses and social workers were great at this, although some small clinics needed a combination team that did the care management together. training was essential. it was a new role for many of our care managers and care coordinators. we really had these competencies

to be worked on. health information technology was essential. every one of our initial practices and most of our dissemination had electronic health record systems but they needed more. and so we helped them to enhance what they had, to use it better, but also to use additional functions around population management and care planning. we found that our technical assistance was really helpful to them and was critical for them to be successful but they could do it. and we found that most of them came back to us very excited about it but since they were paying for this mostly themselves really were talking to -- they needed changes in the payment that they got. we call this pay for pro-active care for care coordination, for goal setting and motivational interviewing for behavioral change and education. many of them also find that per member per month is helpful, although selecting populations is really helpful to see some

cost savings and the clinics really needed to be able to refer whoever they could -- that they saw the need for, into the program to make it work, to make that efficiency work. so that's really what i had to say. thank you again for having me. >> thank you. sue, take us to colorado. >> thank you. it's my pleasure to talk about the medicaid medical homes for children pilot that we initiated a couple of years ago. and i'd like to share some brief background to put it into context. when governor bill ritter came into office in 2007, healthcare was a top priority of his administration. and there was really a deliberate decision to focus on children's coverage and health access issues. and while we have a couple of excellent managed care plans that participate in the medicaid program, the vast majority of our medicaid clients' children

are seen in a fee for service model. and for us, that raised some serious concerns or questions about the sustainability and increased costs associated with that fee for service model. it also raised some questions about the extent to which children were receiving preventative care, getting their immunizations, -- having care coordination. it raised serious questions about access. at that time, only 20% of our private pediatricians and family practice physicians participated in the medicaid program. and of course, you know, at the top of the list for not participating is the lack of reimbursement. but when you really dig down a little deeper, there are a variety of barriers that primary care physicians list as barriers to taking medicaid and s-chip

kids. for example, there is a very high incidence of missed appointments. and we know why there are missed appointments. because this population sometimes have challenges accessing transportation to get to medical appointments. we know that there are social supports that are needed to support these families that there are a lot of things that need to happen in that family's life other than just accessing healthcare. there are housing issues and economic job-related issues. and so we had all of these concerns. and also in 2007 legislation was passed. medical home for children's legislation that mandated the department implement systems and standards for medical homes for children so that -- to maximize

the in many of children that had medical homes. and that was all supposed to be done in 12 months. so in government, that's a very short period of time to implement something. and so we had to work quickly and we had to work smart. and our approach was really to leverage the existing programs, resources that were already in place to create our pilot program. fortunately for us, we were well-positioned to do this. our sister agency, the department of public health and environment, their title v program had been involved with dr. carl coolly's learning labs and learning about medical homes. and out of that work, two passionate pediatricians, dr. steve pool and dr. james todd, created a nonprofit association called the colorado children's health access plan which was really designed to

recruit more private primary care physicians to accept medicaid and chip and then to provide support services for those practices. and we also have a very robust e.p.s. opinion p.t. outreach in case management program. we have outreach workers situated throughout the state that have been helping families value and use healthcare and they really serve as that -- in that health educator role. so we liken this to creating a reese's peanut butter cup. we've researched all the best aspects of what we were doing in the public sector and join them with what the good work that was being done in the private sector and created our medical home pilot. our pilot design, we had 28 c-chap practices that included

about 11,000 medicaid children. c-chap, the nonprofit association, provided 14 support services to the families and practices. and then the department, we reimbursed a fee to the c-chap practices and we aligned the payments to preventative care. so we tried to innocent advise behavior. -- incentivize behavior. we gave $10 per preventative care visit birth to four years old and from five years to 19 years, $40 per preventative care visit. and we used existing codes to provide that enhanced reimbursement. now, that doesn't sound like a lot of money, but it was enough money to get us going and in the right direction. here you can see our e.p.s.-p.t.

outreach. they are really serving as the care coordinator role. they are sort of again approaching it from the holistic viewpoint of the client looking at the life cycle of the client, everything that has to happen in order for a family to access healthcare services. they work in the community, identify resources and link those families to those community resources. because this pilot is focused on children, colorado has a very unique sort of philosophy. we are very much family-centered. i know there's a lot of talk about patient-centered. but when you're working with children, you really have to look at the whole family. and so we have a very -- we have a family-centered medical home model. and then our c-chap physicians

serve in the primary role of providing care and helping do the care coordination. the c-chap continues to provide the support services, interpretation services, linkages to mental health services, again looking at the whole child. so what are the results of our pilot? as mentioned earlier, 74% of our medicaid children in this pilot had a well child visit during the 12-month observation period compared to 56%. we saw reduced costs of care per child, improved health outcomes, increased immunization rates. in 2006, colorado was ranked 49th in the rate of childhood immunizations for our medicaid kids. we have raised that. we're 26th now in just a very

short period of time. and we believe our medical home pilot and our work in this area has been a big contributing factor. preventative care visits increased as previously mentioned. emergency care visits and hospitalization rates have also decreased. now, it says there on the slide that we are collecting baseline data too. but miraculously over the weekend i was able to obtain some data on the physician and client experience. c-chap surveys the providers participate 0% satisfaction rate. -- 90% satisfaction rate. i think it's significant. my favorite story about a private practice is that dr. pool went to a high-end pediatric private practice, never took medicaid or s-chip kids. he led one of the fizz eggs to the window and said, "look out

that window. did you know that 33% of the children that live in this neighborhood are eligible for medicaid and s-chip and you don't see a single one of those kids "? that exchange, that dialogue, that communication was a turning point. i don't know if it was guilt. sometimes guilt works very well. but that pediatric practice started taking medicaid patients. and again, i think physicians say they're willing to see our kids. they just need some help with some of the barriers. and working with vulnerable populations. the family experience, one parent quoted the medical home is building relationships. 96% of our families feel their child's provider creates a medical home for their child, 100% feel the provider values

the child, and the child's family, and 100% feel the provider meets the needs -- family's cultural differences. >> sue, why don't we move to significant that and you can chime in the conversation? >> did i go over? i tried so hard? >> your enthusiasm is -- -- you have a couple good thoughts for how to scale it. maybe we'll bring this into the conversation. i want to make sure everybody gets team and we have the discussion. so barbara and richard, if you could talk to us about what you're launching up at dartmouth. >> i'll go ahead and start. i'm dick salmon with signa healthcare and i'm joined by barbara walters. we're please today share with you the partnership that we have developed over the last several years that really resulted from a challenge our senior leadership gave to us 18 months ago to accelerate the improvement in both quality and affordability of the individuals that we served in common.

at baseline, dartmouth hitchcock, as all of you know, has superb clinical reputation. over 1,000 physicians who provide excellent care in both urban, rural, and academic settings. and parallel to that we have cigna healthcare who over recent years has developed robust health advocatesy services, both teletonnic and internet based case management, disease management and wellness services as well as pretty significant health infomat ex services to guide the improvement in care. we had two problems. first of all, these clinical efforts were not ideally connected. so two systems running in parallel and we weren't getting the synergy we wanted ou out of connecting those two systems. the second was that our primary

interaction to exaggerate the point was a periodic no, over fee schedules every couple of years and it was not an interaction where we sat down together and said, how do we improve fundamental value? how do we improve both quality and affordability, and how does the plan reward dartmouth for doing that? so we developed a new program together that has the key concepts outlined there. and i want to emphasize just a few of them. one is we said that program had to operate in the open fee for service environment. that is this has to be a program that didn't require people to work through their primary care physician, but rather provided incentives to members to work with their primary care physicians because the physicians offered enhanced access and enhanced care coordination. so it was improving the care coordination delivered by primary care physicians, not by forcing people to work with their primary care physicians

but by provide such excellent service that that's what people wanted to do. the second is the rewards for the program had to be based on an improvement of both quality and affordability. it wasn't just about quality and it certainly wasn't just about affordability. both had time prove in order to provide rewards. and we need to administer those rewards through a different payment mechanism. instead of just increasing the fee for service payment, pay the rewards to a periodic care management payment. the third was we wanted to obtain synergy. so leverage the strength of dartmouth's direct face-to-face clinical programs with cigna's teletonnic and internet-based programs and with our advanced analytic and health information services to identify patients who are at risk and identify gaps in care or care improvement opportunities. so with those three fundamental concepts we began designing our program in january of '08.

we implemented it about a year ago. and we'll have our first level of results later on this fall in about november. at this point what i'd like to do is to turn it over to barbara who will tell you about the real important aspects of the program, and that is how it affects individual patients. >> thanks, dick. as i mentioned earlier, dartmouth hitchcock participated in the medicare physician group practice demonstration project, and we were able to show increased quality compared to benchmark and national targets as well as savings through the our three years of participation in the program. and we were absolutely delighted and looking for a commercial partner to see if the same thing that is we had designed that are listed up there under practice resources would be applicable to a commercial population. because it really is a different patient population. so i'm just going to tell you a very brief story about one of our patients that i hope

illustrates that we believe that we're on the right track here. so i want to talk about mary. mary is your next door neighbor. my next door neighbor, could be my sister, could be any one of our sisters. she is married. she's been married for about 30 years. her husband works. he's fully employed. he's insured by cigna. he is a tradesman. they have a company of kids, a couple of grandkids. mary loves to cook and she really likes to scratch book. her husband is a hunter and a fisherman, live in a small town in new hampshire. mary has insulin dependent diabetes and she's a cancer sur. she was referred to one of our care managers by one of her primary care docks who she sees most often because he just thought she was depressed and she wasn't getting better. no matter what he did, he really couldn't make her mood improve. and our care manager was asked to do what care managers do, get to know her and make a referral

to a local mental health provider. at the time that our care coordinator contacted mary, and i think dr. kocher earlier said you can call and get answered by the first time. we actually call our patients before they call us which i think is really good sometimes. and we do a screening tool for all of our patients in primary care. the personal health questionnaire nine which is a score for depression. her score was 22 which is very, very severely depressed and perhaps suicidal. our care coordinator was able to at least connect with mary and began speaking with her on the phone every week. they set small goals. sometimes they met the goals, sometimes they didn't meet the goals. she learned that mary grew up in an orphanage. and through the most of mary's life she was scared, she was shy, she felt invisible. she was frightened to get involved with people. and she was the actually barrier to going to a mental health

visit, not her husband as she had previously reported. and in fact, she started telling us that her husband was so worried about her he began taking time off work to stay around the house with her so that she wouldn't do anything to harm herself. so we're also losing employed time from the employer's perspective here. she said that when her husband was in the house the thing that kept her going was thinking about her grandkids. one of the things that our care managers do all the time, and i'm sure they do it all the places we're talking about is medication reconciliation. so she would take the medication list that she thought may was on and the medications that mary thought she was on and tried to make sure they agreed on the same medication lists. the and it just wasn't working. we've got this really spiff if i medical electronic records you can print out a patient's medication list. the we mailed it off to mary because they weren't getting the words right. called again. and lo and behold, mary admitted that she really couldn't read very well.

so she really didn't know what our spiff if i patient friendly medical reconciliation list said. so our care manager scheduled a visit, brought her in. her husband came in as well. and god bless this woman. she sat down and color-coded and drew pictures on every single bottle of medication and on our spiff if i medication list that patient couldn't read. she put a frowny face for the antidepressant medication. she put a heart for her medication for her hypertension. and she did something with food for her cholesterol medication. and at the same time, we were interacting with cigna and cigna shared with us that mary hadn't in fact filled her antidepressant medication in over a year. it's really hard to get better from a medication if get it filled. we involved the community, her church, the visiting nurse es association. mary is taking all of her

medication. her husband hasn't missed a day at work in over i think about six months the last time that we looked. her score, her depression score is down to 9 so she's in contr control. so i think that's the core of what we're trying to do. we're trying to work with people living real lives doing real things, fully employed, getting information from cigna that they have that we don't have, getting information from our care manager. we have a doc who knew something wasn't right, we had a care manager who wouldn't give up and we had some information from cigna that really put this all together. and that what we think we're trying to do in this clinical collaboration. and i'm going to get my slides and close on. that i hope that we can spread. this and we do it in urban communities. we do it in all communities. we do it in large communities. and we think that this is what advanced primary care practice is all about. the docs love it. it takes off the burden of the paperwork.

they get a patient who's ready to talk to them. the nurses love it. they're being able to practice nursing the way they want to practice nursing and what they went to nursing school for. and patients are like, oh, my gosh, you called me. i didn't even have to call you. so i think that's what we're hoping for. thank you. >> bob, we had a slide that showed the payment ail ga rhythm. that was before this one. but i guess it actually got left out. so i can just speak to one -- >> the mary story was one that i'm glad that you shared. how does it work? >> ok. so again to make all of that work we have to align the incentives. and so what we do together with dartmouth is agree is that we will track both -- we will require both improvement in quality and improvement in affordability, and affordability is measured by total medical cost and the trend in total

medical costs compared to the market average so they're measured against their peers. the improvement in affordability essentially funds the bonus pool. and then how much of the bonus pool dartmouth gets depends on how much they not only improve affordability but also improve quality. and that payment is made through a periodic care management payment onto the go. code system rather than as a modification for the fee service. so we feel by getting the reward system lined up, synergy in the infomat ex, synergy in the working together between dartmouth and cigna that we're able to drive a much better outcome. >> thank you. we're hearing wonderful patient stories. thank you for sharing mary. michael? >> i'm dr. michael soman, president of group health physicians. like all of you we seek better care at lower costs. and we found that one year a 29% reductions in emergency room and

urgent care visits in our pilot paid for itself. our practice has 900 physicians, 250 primary care practices and cares for about 400,000 patients in the state of washington. we have made a strategic long-term commitment to effective primary care to apply to all of our clinics. first we ran a two-year pilot. and we learned from that pilot many things that helped us identify the elements to apply everywhere we were now about actually two-thirds of the way through using lean processes. in short we learned that upfront investments in primary care lead to better quality, better patient and staff satfaction and stabilized the medical costs trend. so what this really is about if i can have the next slide is putting the patient-physician relationship at the core of all we do. and then supporting that relationship with high-quality information, strong teams, and great access.

this allows the teams to address each patient's acute chronic and prevention needs. that's it in a nutshell. so what did we do? first we invest in our primary care teams. we added 30% of staffing. physicians, nurses, mid levels, pharmacists. then we decreased the number of patients that each physician is responsible for, from 2300 to 1800. increased the visit time on a template from 20 minutes to 30 minutes. and then we hit on real goals. we finally figured out how to really leverage our electronic medical record or e.m. r. and i have a key point about this. that it's not really about the convenience that these records allow for both patients and clip eggses, though that convenience is huge and can't be overstated. the real power in these systems comes because they allow us to know or patients so that we can pro actively address their care

needs. that's what makes them really work. and we can address these care needs through a variety of processes from focused, outreached complex patients to simply knowing every patient's prevention needs at every visit and delivering on them. this of course increases our quality scores which is nice. but more importantly it allows us to know what to do for each patient at every visit. we can also address populations of patients. example: 2007 we put in a new process to care for our 7,000 patients on blood thinners. we shortly decreased clots and bleeds 26%, saving over $3 million while giving better care. last point about e.m.r.'s, clinicses through the our system are adding to the evolving story about each patient. this kind of collaboration deepens our understanding and makes it pretty easy, actually, to give up-to-date, seamless

evidence-based care. about access, we changed the paradigm. we said patients, you're in charge. you tell us what access works for you. group visit, traditional face-to-face visit, e-mail, security message, phone visit. what works? you're in charge. we found that we could often resolve their concerns with a phone message or secure message, saving them time, cost and convenience. patients also can access their records, e-mail their doctor, order medications and make appointments online. this engages them in their health, strengthens the bond between them and their doctor, and ultimately puts them right where they belong at the center of their care experience. the results of one year, if i can have the next slide, are gratifying, at two years they're even better. i need to point out the error. the first line under cost productivity says we added 29%.

that's wrong. we addedded system for all of it, which was about 8% in primary care. so at one year as i said we saw 29%, that's where the number came from, reductions in e.r. visits and urgent care visits. we also found 11% reductions in am blah story care sensitive hospital admissions, the kind that do well with good am blah story care. the reductions in utilization actually paid for the pilot for one year. we didn't expect. that i had a briefing last week about the two-year results and it's even more come pelling. i can tell you this much. it saves money, lots of money. also improve health outcomes like cholesterol management and people with core on air artery disease or diabetes. it enhanced work satisfaction, decreased burnout, increased patient satisfaction. we now have 12 applicants for every physician we post in primary care. think about that given the primary care shortage nationally and in our state. so based on this findings we're rolling it out to all 26 medical

centerrers, about two-thirds of the way there. we identified the key ingredients for our system. we think these elements can be translated to different practices with different payment mechanisms and lesser levels of integration, and m'scaps need to be supported by reform. example, we need innovative payment mechanisms that allow quality, integrated electronic medical records, more development of medical homes, collaboration between providers. that allows teams to for the whole patient across the continue up of care. that's how you get the benefits. most important of yours is the experience of patients so i want to close with the words of a delightful 80-year-old woman. not only today but continually, no matter when we come, we are treated promptly, courteously, cheerfully and efficiently. in recent visits we are aware of an extended time with the doctor, no longer a sense of rush. to everyone from the front door

to the end of our visit, thank you. keep up the great work. thank you. >> thank you. great story. craig. talk to us about vermont. >> sure. first off i want to thank nancy-ann, and bob, thank you both for being able to be here for the benefit of the state of vermont. one thing that drew me to vermont two years ago was the environment there and the commitment, the willingness of the leadership in the state, the governor and the legislature, to really take on healthcare reform and do it in as comprehensive a way as you could imagine. and it's really visionary leadership. and i think that's where this starts, when you have in our case a bipartisan willingness to come together and to work on complete healthcare reform the. and that's what's led to us where we are as a state right now with our healthcare reform models. and i would just summarize it by saying what the state really wants to do is build this

coordinated, well-integrated, high-quality system of health. and where we started from, we're starting from a typical tapestry like the rest of america with independent practices, some big, some small, some affiliated with hospitals, some federally qualified health centers, poor areas, more dense and urban areas. we're starting with the same tapestry. how do you turn it into a coordinated system of health? so if we start off with the first slide, it's a summary of the timeline. and we're in the midst of our first pilot. and really working on testing this out across this mow sayic, this -- mosaic of healthcare environment. we're working on three different communities. we hope to have about 60,000 patients enrolled in the pilots testing this new approach to healthcare. you can see the timeline on the bottom of the slide. we started planning this in 2007. that meant negotiating the financial reform, designing a payment model that could really support high-quality care, it

meant designing the health information technologies that would be so critical for this. it meant putting in place the community health teams. and so we spent about a year getting the design, the strategies up. and then in july of last year we started with the first pilot community october 2nd. and we're now getting ready to gear up the third pilot community. just as a brief summary of this, the uptake has been tremendous as we've heard from the other participants with the docs, with the patients, with the families, and even with some surprising the hospital c.e.o.s, the uptake of this and the engagement of this, the acceptance of this has been fairly rapid and so much so that actually this year, starting this summer, working on statewide readiness for expansion of the model. much faster than we would have anticipated. so if i go to the next slide i can just give you a key breakdown of what the components of the healthcare model is. it really does foe into being

able to operate with just high-quality delivery. and so it starts with the payment reform. and the payment reform that we've negotiated is with all of our insurers involved. i want to stress that. it's really critical to have all the insurers involved in this. so our major commercial ensures and medicaid, they're all paying the same way. and what happens is the practices get scored based on national standards. our mcqa standards. this drives based on the quality of care, how thorough the care is, the great access, the practices get enhanced payment. it's on top of their normal fee for service. what are we doing here? we're beginning to balance out the pressures, the incentives for volume against incentives for quality. beginning to balance out that scale where it was all volume before. but that part of the payment isn't all it's limited to. it also includes our insurers sharing the costers for what we call community health teams. and these teams are a critical

component. so the teams are made up of a whole mix of profession also. they include nurse coordinators, social workers, mental health counselors, dieticians. the people you really need to make thorough, high-quality healthcare work. now, the idea of having all our insurers involved and the idea of having a health team not limited to a practice is, how do you scale this? how do you work in a world where you have a small, independent, single practitioner versus large group practices? where you have some practices that are spread out in rural areas, others that are in more dense urban areas? how do you build a model that can work across this whole setting? so that's the idea of the community health teams and of having the insurers share the costs that these teams can be expanded, scaled, include the number of people, the right mix of people that they need to serve a collection of primary care practices, not just one. and then the primary care practices are paid for delivering thorough care. and what we've seen emerge out of this is an incredible

approach to well-coordinated care. because we start with a team of five people in the community health team. but that's the new people that are put in place. what happens is they do such an effective job of linking to social services and other services in the community, the functional team is much bigger than the five. and we're seeing it translate into tremendous case examples. and i was listening just thinking of one i asked one of our docs for case examples today. and one classic example, very similar to what you described, is a 62-year-old woman living in a poorer area in vermont, lower socioeconomic area. came in to see her primary care doctor maybe once every two years. she's got diabetes. came in last spring. turned out she had an elevated depression score, never really engaged in her treatment plan or getting control of her disease. turned out that she was more worried about the rest of the people in her house, being able to get to their healthcare. the doc was able to attach her

to the community health team, the nurse coordinator, the mental health counselor. they began to work with her, connected her to social services that got her transportation to the practices. in july, just a few months later, she now has really solid control of her diabetes, she's had tremendous improvement in the mental health issues. and this is a classic example of a patient that was going to be ripe for the worst possible health outcomes of chronic disease with depression. she was going to be sick, she was going to have terrible outcomes. she was going to cost the health system a large amount of money in terms of hospitalizations. and within a few months the teamworking with the primary care doctor was able to turn that around. and those type of experiences have really led to rapid uptake in adoption of the model in the state and the desire to expand this statewide. the health i.t. is part of this. the information technology is a core part of this. but it should live quietly behind the scenes, helping

deliver, helping drive great care. it shouldn't be the focus of it. it should be the architecture that supports it. so we have electronic medical records where they have been connected through the registries with the health information exchange so information can pass back and forth and the core information is where it needs to be for the community health team members and for the practices and the people working within the practices. .

>> on the slide, our hospital ceos had unanimously agreed to work with us -- we are statewide recognized and we're beginning to ordinary -- coordination for primary care practices. should we be able to expand as, they will be able to do that quickly. moving on to the next slide, thinking about evaluation, we have a core set of measures to evaluate this. looking at the quality of health care -- you improve the quality and you have a new payment reform, information technology, if you have this new environment this changes the way the quality of care is delivered.

if it does, patients get more screening test and assessments that they need. they get more of the assessments and they stay engaged and come back on a regular basis, all the rest is changing the health of this population. they shift to more preventive care. if all that happens, what happens financially on health care costs? and to that extent, we have put in place of robust set of databases and we will look carefully at all these layers. the last thing about one mentioned, what we really need for this to work -- we need have more complete present occasion of all our insurers. we need to work closely -- we need them working closely with this to expand this throughout

the state. thank you for this opportunity. >> thank you for the opportunity to be here today. and in the greatest system in teaching hospitals and insurance companies -- we are not mutually exclusive. other ensure networks use other community providers. in 2006, which included that we needed to develop a new care model to develop models for our medicare patients. our objectives were to improve the quality, care, and experience of the patients. we also believe that that health care financing was a zero sum game. we had to do this without increasing the total cost of care. the navigator model was the result of this. we introduced it to one pilot practice in 2006 and rapidly

expanded it to 35 hospitals. the model was built as a partnership between our primary care physicians an hour in currency -- and our insurance companies. the strategy was to provide 24/27, 360 degree care and guidance for our patients. at the center of our redesign effort, we've delivered a system to deliver high care system -- high-quality care whenever and wherever it was needed. it included a case manager in the office and in the specialist office, in a nursing home or hospital. next slide, please. a similar system was a foundation of this effort.

we expanded access, and nurses provided many routine services, from our electronic health registry. the nurses were reminded to order to -- order the -- the nurse is reminded her to order the proper tests. when she is not home, see can be monitored. we moved our population management plans to the pc peake -- pcp offices. manages used our predicted modeling tools. it helped them develop an end of the july care plan. when she finds her condition worsening, she can call her case manager using a dedicated phone line to get immediate advice.

when she is hospitalized, she can arrange to be seen in seven days. it would improve the services provided outside the primary- care practice. but all is to identify ancillary providers to help with this valuable mission. it would also optimized systems. under our program, each practice would have quality and dissidents targeted on improving joint quality metrics. the teams meet monthly to review their progress on these goals as well as goals related to that member experience and cost of care. during these meetings, they also discuss individual cases, trying to identify opportunities to improve care. the value reimbursement program

at a news stipends for decisions in practice as well as a shared savings incentive model to our pre-existing performance programs. all payments are best -- based on quality targets. we believe that the improvements and the total cost of care woud cover it. we found that care coordination demonstrated positive results quickly. within three months, and reduced admissions within six months. the next slide, please. this is also been positive for our first 11,000 members. these results were measured across the entire population. there is no regression to the meaning.

we believe that these results can be projected over our entire medicare population. one health status, we scored significant improvement in our metric for measuring compliance with outcomes for diabetes. coronary artery disease, as well as a preventative care services. readmission is decreased 25%. total emissions decrease 15%. total cost of medical care was 70% debt and our medicare population. the next light. in conclusion, we learned that it is possible to deliver more value for our members. this model is strong. there was a two to one return on investment. we're currently in the process of designing and implementing a multi payer program in northeast pennsylvania. care management is essential.

they had been resources for managing individual patients and providing a focus for our efforts. the partnership approach was important because a group from the really big -- a group from the realization that no one could do this alone. he needed to be a partnership. both sides have strengths and ordered a successful. electronic health records were helpful but not essential. the most essential aspect of the model is to establish a context that drives the practice and caucuses on delivering high value in comes to individual patients and their populations. realign the proper -- but we're delivering these outcomes. we found that get doctors are reason to deliver an pursuit value for their patience and we support their practices for

operational and harassment, and the care team would deliver in the short term. thank you very much for the opportunity. i look forward to the discussion. >> this has been fascinating. i should have said at the beginning that what is great that is all of these experiments and projects are well under way around the country and showing a lot of positive results. but also there has been some activity in congress are around trying to help the efforts, building on the things that you have been doing. in the recovery act there was funding for additional preventive health care activities and management activities. in addition, the house had built that three committees have put forward which does have funding for pilots are around, doing more this around the country informed by the things that you have all done. it is not like we're just

talking in academic circles. this is already happening and congress has taken note and is trying to move it board. the u.s. something about that a session? -- the you have something about the discussion? >> i will dive right in. based on what nancy was saying, one of the things that would be interesting to hear from you, with these great examples, how do we take that to a larger scale, to a national scale? what are the things that we need to consider? how do we go about doing it? >> i can have died in. -- i can divan. -- dive in. [inaudible] we have anything from 70% -- 17%. [unintelligible]

we firmly agree on a set of principles that we give to you as a gift. we get organized primary-care. everyone around this table are doing a prior let's -- the pilots from these principles. it is just more than care coordination but it is comprehensive care for all of our patients. that has to be foundational for us. there is no other civilized nation on the face of the earth doing health care without that fundamental foundational understanding. my members and my patients want access. they want convenience and be able to use to like e-mail to communicate with their doctors. that is fundamental and foundational. the current bills that you talked about, they are great. we support them.

but they focused narrowly on chronic disease, and when you did that, you miss the whole point. this system is designed for everything. they are integrated. >> let's go around counterclockwise. >> what can we do to move this for? first of all, help fight t, there is an opportunity -- health i.t., there is an opportunity to clearly send the signal to the industry that there are standardized ways and the systems need to work. they have to figure out how the systems work for them.

there is an opportunity to make that clear for people going forward. and then the regional centers, [unintelligible] we can support them. and then finally -- you can achieve a lot of coordination of care but is hard to achieve right now without the kind of in probability and when systems can talk to each other. >> out on a thank you for providing the data. it's important to understand that there's a lot more information than medicare demonstrations. if you had not publish the data, i would encourage you to get that out there and publish it. on scaling and replicating, i

would focus on the functions. i heard some common themes across the board here in terms of the key functions that really seem to be effected in driving these results. one was integration of the care coordination with the physician practice. we learn that from the medicare demonstrations and also from the work in north carolina, vermont, and some of the other models as well. that is essential appeared set it is building a transitional care compound appeared this is critical in the medicare program where you have 20% of patients we admitted within 30 days. we can reduce the bite 25% to 50 percent -- to 20% if you have a program targeting that. it is also important and we learned how not to do that in the medicare demonstrations. we have seen the value of how to do it in these programs for the fourth piece with the of population-based primary prevention. we talked a lot about convention

in terms of detecting disease. that is important. but of birding disease and the first place is as important -- of working -- averting disease in the first place is as important. a feedback component, how well we're doing in providing that information organically to the systems, i think is critical as well. and the final point i would make his payment reforms. i'm thinking about fee-for- service medicare, but financial incentives and some of the structural changes i think is an important part. i would target those functionality is, because it targets the contents, we can scale this. we've seen it in vermont and in north carolina. it is the direction to go. the current congressional bills are on the right path. the issue is, can we improve on those? can we keep pushing? i hope so.

the unemployed is certainly what may put on those bills is what we're doing now. we're going in the right direction. there are a lot of lessons to learn about how we can improve this in our current discussions. >> bob, and and and. >> i appreciate his point because he saved half of my talk. it allows me to say something else. what ken pointed out is very important. they have common vision and goals. they got there with some variation but they can learn from each other. that is fantastic. that says that you have a model that is scalable, that is impermissible. what i wanted to talk to -- we have done an evacuation of primary-care stand-alone network in taxes that 15 years. there really is the variation in scali ability. but out facilitation and leadership and vision, without

getting all the players involved, this goes from a two- year process to a 15-year process. take some organization, particularly as craig was saying, areas where you have a three-person practice, we need to facilitate those people getting there. you need help with the payment reform, the community care teams, the public help denigration, getting set up for them and getting involved in the process. that will take you from a two- year process to a 15-year process, or the opposite depending on how you set it up. >> two quick thoughts. education, communication about what this is and what it is not. the american public would be excited to hear what this is b.s. not what it is not. communication, these types of sessions and putting out on a broader platform would be

certainly helpful. bring all the governors together and share the stories. you hear a common theme about leadership. we get chance to spend a lot of time with the state agencies and the governors are looking for ideas like this to get at cost and quality. they would be receptive to use sponsoring something to bring them these kinds of ideas. the third area, incentives. we need to bring health plans into this conversation. it is great at cigna as a part of this health-care conversation. independent of all the things that are going on, so bring a man. bring them into this conversation. that is very healthy. primary-care education. we need had i resurgence of primary care physician. we need to look at that teen care models. you've heard about care management. start calling that out and encouraging people to build new medical skills that would have primary care as a foundation.

new care management, that would be very helpful. your voice heard there would go a long way. and last, but not least, encourage this level of the incubation period find a way that find these projects, whatever it might be. any money that you have to continue to drive this. we can shorten 15 years to two years based on those experiences. buzz about five things, communication, later said, incentives, primary-care education, and continuing to find a way to fund these projects. >> anything hard about the comments? two more. >> congratulations and i think it is remarkable how functions around primary-care have all been satisfied in each of these. first contact, continuing conversation, an important care. and it is important that

everyone has held on to the key element of the chronic care model. data and the management systems, a shared decision making -- those are all key elements that everybody has. what we may need to think about now more, think about this from the patient's point of view. as one thing that have a patient experienced integrated into the health system and have an experience there was series of communities where the patient has to go from practice to hospital to wherever. i'm very interested in a point of view of state-based initiative such as allen and craig mentioned, and susan compared to the integrated health systems. how can we turn this around from a patient's point of view? so that they will expecting get the same quality and care as community care?

>> i just want to see very briefly that one of the calls is a better coordinated care and that we not have the uninsured in this country. as you are looking at primary care, i need you to look at the system that they have in richmond, va.. coordinated care for the uninsured. he gives all the medical home in a primary care network. these are all people that do not have access to health insurance today. i know that they are doing some of that in north carolina, also. there are a couple of the models out there for the uninsured right now. >> unusually. i think i shock you. it must not be feeling well. i agree with all the comments and i appreciate everyone sharing their experiencing its. look, falls, there has to be a vision here. and this is in your balak. we talked about this before, bob. it is a vision about what health

care in this country should look like. absolutely we need to cover everyone in this country but that is the first part of a transformation of what health care should be. we are not doing a good enough job. for many people, it is good but it is not great in it is not allowable superb care that shetland -- everyone should be getting in this country. you hear pockets of where that is happening, where everyone would love to go to blow out and say that the type of care that every american should beginning today. -- should be getting today, whole person, patience centered care that is built on a solid foundation of primary care. that is not a governing if those of this health care system right now. it if those -- that is not the governing ethos of this health- care system right now. from the medicare program to the medicaid program to that payment schedule to the investment in

medical education -- there has got to be ownership and a willingness of vision to say that is not buying as high quality patient senator sustainable health care. we need a new vision and the white house is willing to articulate a vision that will go round this type of care and a half to be built on that foundation of primary-care. if the emergency is that the foundation is crumbling under our peak right now. half as many people going into general and family medicine as there was a decade ago. this is an assistant -- position -- decision -- phys ician's assistants. i would like to see that articulated. i like the public to get that. this is why every american has a stake in health care reform, because it will be a system that

works for them. we need to look across the board of what we need to do and rebuild that foundation. >> that is a good conclusion. i think you have heard that vision here today, kevin, manifest in what is going on around the country. i am a glass half full person. i was thrilled to see that there was as much dissemination of this model as areas. -- as the areas. i did not realize you are spreading out summit. i've been to vermont and talk to doug -- gov. douglas who is a great spokesperson for the cause. i think he does talk to other governors as well. i think that is what we are aspiring to hear. with the work of everybody in this room, we can make it a reality. >> and i agree with you. there are good elements in the

bills put forward and we need to share -- make sure that they are staying there and they are strengthened. >> thanks, everyone. >> thank you. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> we continue the discussion on the u.s. health-care system tonight on c-span. coming up in a moment, a forum from the alliance for health reform. the health-care system in massachusetts is discussed. after that, keith epstein of "business week," on why health

insurers are winning. after that, on a joint news conference with the prime minister cannot and the presidents of mexico and america. the oilers on tomorrow morning's "washington journal," andrew exum will talk about the security situation in afghanistan. after that, linda douglass joins us. in phoenix mayor gil gordon on challenges facing u.s. cities. and later, an update on the economy with gerald seib of the "wall street journal." later in the day, a conversation on retirement and so security. we will hear from white house national economic council director lawrence summers. watch live coverage at noon eastern.

>> and now, all forum on broadening access to health care. participants discuss the legislation before congress and the outcomes of the massachusetts system established in 2006. the alliance for health reform is the host of this event. it is about 90 minutes. i want to welcome you to this program. i am with the alliance for health reform. thank you for breaking a hot weather in washington to come to this program. you probably remember how cold you were the last time you were here and thought that was a great idea. to spend an aug. atherton in the air-conditioned comfort here. but that is not all of you were going to get for your money.

you're gonna have one of the best programs you will have a chance to be a part of on the extent to which efforts to reform the health care system will affect the access to health care. i want to welcome you on behalf of senator rockefeller, senator collins, and our board of directors. you can be welcomed by them directly here in a moment. but while back, i turned 65 and became eligible for medicare. i got my card in the mail. but i knew that getting that card actually meant i had to go out and find a new primary care doctor, because my previous one did not accept medicare. i eventually got a fine primary care physician and i appreciate your concern, but the point is -- [laughter]

adding insurance is very important to getting access. after all, the institute of medicine indicates that 18,000 americans die every year who would not take -- if they have had health insurance but there are other factors that affect whether you actually get the care that you need. we're here today to talk about some of those factors. we know for example that there need to be enough primary-care doctors and other providers if people are going have adequate primary care access. and to the young professionals, they are not going into primary care in our medical schools and associated schools. we know that relative to specialists, they have lower incomes. and they are reimbursed for up before a service. it offers no incentives for caring for patients in the most

efficient, high-quality, effective way. a partner -- our partner in this as very strong interest in this topic. a self identified as working to help americans get the care that they need. we're very pleased that their involvement in the formulation and the execution of this forum. i want to thank david colby and their colleagues at the foundation for the interest and support. a couple of quick logistical items. there will be a web cast available tomorrow on kaiser family foundation's website. you will find copies of materials in your kits. the biographical background on our speakers is far beyond what i have the time to take to give

you today. you'll also find all that material on our web site. if you are watching on c-span, everything that the people have in front of them on paper is on our web site. you can follow along even with the presentations, the powerpoint presentations, yet that is what you want. at the appropriate time, and those of you in the room can fill out the green question cards in your packets and haul the mob and we will ask the questions that we can get to. there are microphones at the front and back of the room that you can use to ask a question yourself. at the end of the briefing, i would appreciate you filling out the blue about creation -- evaluation forms. let me get back to the program. we have a terrific group of panelists today.

respected analyst, people working on the ground to improve access, and it would give brief presentations. in return to a discussion including your question and we will start with susandentzer -- susan dentzer. she is not on an hour -- on air analyst for the news hour. she let our reporting unit focusing on health care and social security. if you rely on them as i do, you'll have a sense of both the breadthe and depth of her expertise. we wanted to bring us up to a -- up to date is what is indeed the various bills on capitol hill. >> that you very much.

belated happy birthday. it is great to be with you all this morning. timmy has fallen the dubious task of attempting to summarize the health care legislation in 10 brief minutes. some of you may know that the house what through this a couple of weeks ago and it took them more than three hours. you are going to get the speed read version of this. i wanted to begin to say, underscoring this point that access is about more than having just an insurance card. indeed, everything in these bills in some way, shape, and form is about access. some time you see that this is an access or portability or a cost issue. you need to think about these things as being all interrelated. it would be great if we could just have the luxury of dealing with one problem at a time, but we don't, unfortunately. we know about the strengths of the u.s. healthcare based on the research of the last dozen

years or so and about the weaknesses. we know that we're going to have to work and a lot of different arenas just to deliver on something that sounds as simple as access. that is what these bills are about. let me move through my slides here. i will quickly talk about the obama administration's reform framework, that top priorities, an emerging details. and now have nine minutes. here we go. there is not an obama plan, notwithstanding what you read, even in the "washington post," which praised the obama plan. but there is an obama framework in which the bills coming out of congress are being organized. you see the attempt to address all of these issues, reducing the high administrative costs, reducing the rate of growth of health insurance premiums, aiming for universe legality of coverage -- moving toward

universal coverage system, so that more people have access, providing portability of coverage -- you can have access to pay health insurance policy and then lose it in the next if your next employer does not offer it. the portability of coverage is an issue. providing a choice of health care systems is that feature. investing in public health measures in order to keep coverage affordable over the long run. we're clearly going have to have a healthier population. if you have health insurance that is too expensive, because most of the population is obese, if you will not have access to health coverage. underscoring the point that all of these things are very much into related. the primary goals of reform, i think, could be summarized in to just three. insuring access to good health insurance -- coverage. we don't want badder mediocre health coverage -- for as much

of the population as possible. we want to cover the uninsured but we also want to bend the health care cost curve. otherwise, no one will be able to afford access, it even the people currently insured. to recap, we know how people below age get health insurance. most people get through the employment-based system. some people do by at privately in the individual insurance market. some people get it through medicaid. and of course, some people are uninsured. how we broaden coverage and all the bills? we actually are proposing to take all of the existing mechanism and stretch them. you can think of various safety nets. every single one of those would be stretched under the congressional proposals. we would shore up the employment based system and create a new pathway for other people to get insurance that is not strictly speaking through the employer base system.

we would expand the safety net for low-income people, and some combination of all of the above is to be proposed in the bill. as i mentioned, but cost these it is extremely important here. -- the cost fees is extremely import here. that toppled line, they have been growing by two percentage points faster than per-capita real act of growth. per-capita real gdp. this is held pretty constant over time. there will be some differences this year because we had a weak economy. but it has held to a surprising degree. why is that a problem? you could say that that is great because they help the economy is booming. yes, but. this is the -- are harvard

college will be updating this soon. stay tuned for the new numbers. but what these economist it is look at what happens if health spending grew at just 1% faster than real gdp versus 2% faster than real gdp. " what happened to all of the other resources in the economy over this time? their calculation showed that if we were standing on the brakes and bring health spending down to just 1% faster than real gdp, we would cut 55% of the entire increase in the u.s. national income for now to the next 75 years to health care. that is if we slam on the brakes. that would mean we have 45% left over for everything else. defense, education, the national arts, and you name it. everything else you want to do if you're like that is not health care, 45% would be left for that.

if we go to% faster, what happens? 124% of real national income goes to health care. everything we're now spending on health care goes into real gdp. all of the increase in real national increase goes into it. we sucks away resources that we are currently spending on other things. ask you how affordable health coverage will be in an economy where nobody is doing anything else but working in the health- care system, or buying health care? as herbert stein once said, things that cannot go on forever will stop. we can be pretty confident that this will stop. but it will not stop on its own. we have to find a way to put on the brakes. how do we deal with all of this? let's take a piece about covering the uninsured. most of the bills for c i medicaid expansion, primarily aimed at picking up people who

do not now have coverage who are in fact the board. it is a dirty secret that it does not cover about half the poor. we're going to stretch that safety net. you see the proposals cluster around this notion that expanding eligibility to 133% of the eligible poverty level. new pathways. we need to get more avenues to help insurance that more closely resemble what people get it they get employer-based insurance. if you are in an employer-based insurance plan, you are in a big pool. six people -- six people do not have to pay more than help the people because all of the insurance risks are spread across a large pool. whinnied pooling -- we need pooling mechanisms. this is the secret behind the

exchanges are gateways. we will hear about how massachusetts put that in place as well. they all in essence of the states that have exchanges worked eight ways or for the national government to create a national exchange. different avenues to create these pulls so that people have access. a portability credits would be granted people lower on the income scale to help them off for the coverage. a lot of debate is how far down you go for that. in addition, emerging from the senate finance committee, we have the notion of applying tax credits directly to small businesses to help them afford coverage. this will help them sustain another aspect of the bill, mandated it on the house side, mandate on the employers to provide coverage, stretching that safety net. we had a number of insurance

market reforms that need to be take place. the leading one is that if you buy coverage and the individual market, you could be subject to pre-existing condition restrictions. if you have diabetes, the insurance company can happily sell you an insurance policy that covers everything but your diabetes. someonthis is more about the ine market reforms. but big question is the role of the public plan. the public plan is also seen by those are in favor of it as another way of ensuring access for people. a house bill, there is one national public plan. the senate health bill talked- about community health plans. and the senate finance committee seems to be coalescing around co-ops. but there is the need for another avenue, not just for

access but also to enact delivery system reforms. and i will say more about that in a moment. i mentioned the employer and the individual mandates. another important focus of the bills to make sure that people are offered coverage and that they take it up. there seems to have been a growing consensus that the whole system is not going to work unless everyone is in the poll. the cost have to be spread across everybody. that is how we will keep coverage more affordable and overtime for everybody. we obviously have a lot of problems in our u.s. healthcare delivery system, side by side with many streets. to a large degree, reform will be about delivery sister in -- system spirits and 75% of our spending is on chronic disease reform, a large part of the delivery system reforms will be figuring out of way to deliver on chronic disease treatment and care much more effectively.

what do people have in mind for doing that? and house bill, brought a party handed to the secretary of health and human services to launch a lot of tests of delivery system innovations like accountable care organizations and we will hear more about that, medical homes, bayou based purchasing, etc. -- value based purchasing, except from -- etc. it works to expand people's health. you heard about midedpac on steroids. i will spend much time on that because i am at a time did and then a couple of key issues on the work force. we're not going have access to care unless there are the right people in the right place at the right time to care for people.

a lot of emphasis in the bills on more training primary-care doctors, expanding the pipeline of people going in the health professions, making better use of team care focus, with others delivering systems. and the major work in progress remains binding the revenues and the savings, putting that package together to pay for this. in on the senate finance committee side, this is still a work in progress. a lot of savings anticipated after medicare and medicaid help finance the cost. what is ahead? we take our hats off to the famous yogi berra. prediction is very hard especially when it involves the future. i turn this over to the rest of our panelists. [applause]

>> there's an excellent website called health reform.org, where you'll find a lot of appropriate material appeared and the kaiser family website updates on the major provisions on the bills. i commend that to you as well. now we're going to turn to dr. nancy dickey. she has eyes challenger of the texas a&m system. she is a family doctor by background. she does share a lack of academic health centers association, and the part i am most proud of, she is a member of the alliance for health reform board directors. she is in a unique position to talk about how to meet america's need for primary-care practitioners. and how well the reform initiatives address that need. she says that every day.

thank you so much for coming out. >> i'm delighted to be here. let me give you welcome from the board. as he said, i have a number of perspectives to look at the issue of primary care, including that i established and ran up family medicine training program and was the interim dean of the medical school for a time. the white conclusion i can draw is that this may be one of the biggest challenges ahead of us. was toppled bit specifically about primary care. there's current widespread debate and a good bit of data that says that we have an adequate numbers of primary-care providers, however you want to slice and dice them. this is a list of groups we tend to look out as primary care providers. interestingly enough, you all look at young but if you are around in the 1990's, we have lots of people who wanted to do primary care. i talked to friends is said that they were a primary care and

ichthyologist or dermatologist. -- anesthesiologist or dermatologist. people are scrambling to get out. but this group that is here in front of view -- unfortunately, some of the same things that has happened a primary care physicians, where larger numbers of our graduating medical students have chosen to go into some specialty care rather than family medicine, general internal medicine, or general pediatrics, as also began to take a toll on a cord that we thought would be a part of the solution, nurse practitioners and decisions assistance -- physicians' assistants. they are drawn to specialities for many of the same reason. how hard they work and how long the hours are, and we will be talking about all these groups as we talk about the increasing

of the number of primary care. the other issue i could not fail to address it that with the profound nursing shortage, and able -- and ordered to see a more -- north practitioners will need to be back of the members. -- we will need nurse practitioners that beat faculty members. -- to be faculty members. what this light says is simply creating more positions to train more primary-care providers is not the solution. as you can see from looking at this, there are unfilled positions in every one of the primary care areas. 10% in family medicine, and some only 5%, but the reality that there are plenty of doctors get more graduates wanted to go into

primary care. the problem is that they do not. and we will talk about the reasons why. the story is more challenging than what this life would indicate to you. while there are example 6% of family medicine slots that don't have money one training and then, there are substantial numbers of foreign medical graduates who come in to fill primary care slots. u.s. decisions -- physicians occupied a smaller number than the numbers you see before you. why did they not go into primary care? how will they be able to attract people into primary care? the first is you, reference by susan, is money. i grew up in a small -- on a farm in a small time and they let this and to me, even on the small end of the scale. but you have to keep in mind that we do not let many down

people in the medical school. they say, you want me to invest the same amount time to become a radiologist or family doctor, but over the course of my career, there are millions of dollars differential in terms of what i am going have to retire on or buy a retirement home someplace, and so and is part of it. i actually had a young person that came out to spend time with me while i was in practice, and thought she wanted to be a family doctor. elected me with great seriousness and said, if i did that, will i be able to buy a house or car? yes, i think so. but the difference is that if i had the choice between $600,000 a year and $200,000 a year, for the same amount of education and actually less work hours down here than a copier, then an awful lot of people wisely say,

why would i not want to go into dermatology instead of family medicine? there are other reasons. it is not about the money. when we get people into medical school, we do not mentor them or to tell them that family medicine were general internal medicine is a good place to go. many times today, we still hear students told that they are too smart to be just a family doctor. i was handing out scholarships and asking a young lady about who in her family was a doctor. she said her dad was. he was just a family doctor. i almost the check back. that is the type of mentoring that we provide. they want to be respected and get that encouragement in the sub specialty care. they watch hospitals spend big dollars in order to recruit the neurosurgeon or the interventional radiologist. but the gut a primary care settings and often they don't

have investment in the infrastructure to allow them to do information technology. it sends a nonverbal message. medical school recruitment. we have good data de young men and women who come from small towns are more likely to go into primary care and more likely to go under rural primary care, and yet the numbers of people going in a medical school increasingly represent metropolitan areas. that is where they get access to education a gift and the high end training. long hours, and additional challenges for rural and inner- city areas that are difficult to me as well. you wonder why any of us would choose to go into family medicine. there are things that we can do. if we can enhance medical school increment. it is not in the bills, but we can talk about bonuses to schools that either have high at

the variability or bring in students from rural areas or non-urban areas. we can do better mentoring. those numbers are not adequate. there are could general internist out there if we could talk them into telling their story more often. the things that are not in the bill, loan paybacks. many times when you were facing the end of this training, you want to be of the pi house and pay back your lungs. we were talking about that earlier. if they give you lung payback at $200,000 for primary care, it might look more appealing than if you have to pay back $150,000 in loans, by house, and make a very small and, as your college. we will talk about opportunities for training. there will be opportunities for people who wanted trained in primary care. but there are plenty of

vacancies despite the fact we close down a number of training programs because they could not fill their slots with students that want to go into primary care. the bill again creates lots of opportunities for additional training. the other thing the bill does is talk about the medical homes. we talked about this in the academy of family physicians and the academy of pediatrics. many of us thought that that's what we had been doing most of our lives, providing coordination of care, trying to help decide when they need a specialist. but the reality is that we have moved away from that in a lot of health care today. patient self refer to pay it -- to specialists. they may have half a dozen doctors treating them simultaneously, all with prescriptions that do not fit well together perhaps. what these bills do is recognize the potential need to change the way we deliver primary care and called it the medical home.

it is an approach to providing comprehensive care for children to adults. they have been very involved in trying to make sure that this definition is represented in the bill language. a couple of interesting quotes suggest that this is not a new thought. william osler from 100 years ago said that you treat the disease, the patient has, rather than -- let me just read it. i am doing a bad job. the good doctor treats that position -- the disease. the great doctor treats the patient who has the disease. primary care embraces the whole thing. giving the financial incentives to create medical homes, to coordinate care, and hopefully in tights are some specialty colleagues to participate in the coordination rather than seem to be separate from that, could in fact move is in the right direction. we talked about what people do not going to primary care.

there are certainly not an up there. you will hear from some people in massachusetts discovering that. let's talk about what the bill does to address some of these needs. loan repayment -- it increases the amount repaid if you go back in a primary care, up to $50,000 in some cases. that is about half what the average medical student goes out with in loans, more than they can currently get. they can also get a lower interest rate if they go into primary care. expanding the national service health -- the national health service corps. there is good that again. if we can entice these young men and women in, the substantial number will stay in primary care even though they were considering of some specialty arena when it finished their payback. decided that what they're doing is fun. payment is addressed in several different sections in the bill.

most of the time it is tied to moving medicaid paid to 100% of what medicare pays. since many of the doctor's face that medicare payment is not good, that shows you how low they are. we think that that is a step up. it addresses increasing medicaid payments, medicare payments, and the possibility of meat and update, separating primary care and some specialty breads. it talks about training and the fact that primary-care doctors tend not a practicing doctors. yet most of our graduate medical education is in hospitals. maybe we should move trading house so what looks more like the practice you will do when you are actually out earning a living. but the money to support a graduate medical education specialty training is tied to hospitals. what this bill does is actually ties