training was essential. it was a new role for many of our care managers and carã!n rb help technology was essential. most of our feminization had an electronic healthcare reston. but we need more. so we help them to enhance what they had, to use it better, and to use additional functions around population management and care planning. we fanlight -- we found that our criticisms were helpful and they could do it. most of them came back to was very excited about it, but says they were paying for this themselves, to sustain this day needed change meant in the payment that a guy. we call this paid-for-proactive care, for all setting and

interviewing for behavioral change and education. mber per month is . 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 so with those three fundamental concepts, we began designing our projects in january, 2008 about a year ago and will have our first level of result this fall in about november. next line, please? at this point what i would like to do is turn it over to barbara who will tell you about the real important aspects of the program and how it affects individual patients. >> as i mentioned earlier, dartmouth participated in the medicare demonstration project and we were able to show increased quality compared to benchmark and national targets as well as savings throughout our three years participation in the program. 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 satisfaction 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 summa i would just summarize it by saying what the state really wants to do is build an integrate and high quality system of health. where are we starting? like the typical tapestry like the rest of america. some big, some small. some poor areas. more dense and urban areas. we're startinging with the tame tapestry. so if we start off with the first slide it is a summary of the limeline. we're in the midst of our -- timeline. we're in the midst of our first pilot really working on testing this out, this mosaic health care environment that we have. we're working on three different communities. 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 heth 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 essenti they are both the resources, managing individual patients. the partnership approach was important because it grew from the realization that neither the practice nor the health plan could do this alone. it needed to be a partnership. we found that electronic health records were helpful but not essential. we have used other tools and held practices without them and. the most essential aspect of the model is to establish a context that drives the practice to focus on high-value -- to individual patients and their populations. we have aligned the finances in the business model with

delivering these outcomes. if we give doctors a reason to deliver and pursue values for their patients and support their practices, the care teams will deliver and deliver in the short-term. thanks very much for the opportunity to participate in this lively discussion. thank you. 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 opportuni -- 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 adáa that is built around whole patient centered care. the emergency in all this is that the foundation is crumbling right now. if there were half as many going into internal medicine as a decade ago. if we don't reverse that trajectory right away, we will not have the capacity nationwide to achieve this vision. n'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]

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 eventuallyot 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. @@@@@@@@n 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 theouse 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@@@@@@g @ @ mr 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 pavement -- payment to the opportunity to do ambulatory

training. if you like it enjoyed, you were more likely to continue in that arena. we need to make sure that the dollar's fall the residence. -- that the dollars follow the residents. this bill would move doctors -- funded positions -- in the primary care arenas. as i said earlier on, that will not do any get unless you convince more of my graduates to go into primary care. it's not that there are not enough slots but not enough people willing to go into those slots. we have to address those other issues before the transition of bonds' fill positions is going to do any good. it's interesting that there are a pilot projects for training into disciplinary. we tend to train in silos. even when we get out of practice, we all have to work as a team. the concept that this team will

be more he dissent than any one of us deficient -- individually is an interesting concept but one that we do not have any money to train toward today. .

we're going to turn now to sort

of a case study of how this works out in a specific place, that is to say, the commonwealth of massachusetts. we've asked our next two speakers to address, first, private sector approach, and then a public sector approach for dealing with the question of access. that means we're going to hear next from debra devoe, the executive director of community transformation of blue cross/blue shield of massachusetts. one aspect of her work is the dramatic new initiative on payment reform which was recely launched by blue cross/blue shield. the c.e.o. of that corporation, i was delleding -- telling debra before we started, he's been describing this initiative at meetings of a commission he served on and that i attended

meetings of and it is a fascinating experiment. while the congressional negotiators struggle with how to reshape health system payment for care in a way that encourages high quality and cost effectiveness, deb and her colleagues in massachusetts are actually starting to do it. we thought he'd ask her to try to explain a little bit of how it came to be and how it's working out. thanks for coming, deb. >> my role will be to talk about how payment can help support access. i'll be eager to hear your questions on how this will work the vision of massachusetts, similar to the vision of our country, i think, is to create a system where all have access and it's safe and affordable.

the challenge for the plan is when physicians, hospitals, and patients look at how we pay for services, what they could say is we do not pay for any of those things right now. we're not paying physicians and hospitals differently if the care is safer or more effective. we're not recognizing them if they manage to produce more affordable care. so we, as health plans, and blue cross of massachusetts feels strongly that we need to play a role in changing that and let's start to pay for the things we all want, safe, effective, affordable care. as you'll hear from sharon in a moment, our state took the first steps to try to provide coverage to all citizens in our state. but we immediately, once we made access to coverage available, we immediately bumped into the issue that care

was still not affordable, was not the safest care that we think we can provide as a system, and was not necessarily the most effective. we have grave concerns about losing the broad coverage if we can't a -- if we can't create affordable care. what we have begun to do is to offer an alternative contract to the providers that are in our network in the state of massachusetts to not -- it's not required for participating in blue cross. but what we are able to say to providers is, if you're prepared to accept accountability for cost of care, effectiveness of care, safety of care, you will be recognized. with greater revenue. if you can produce that. so the basic structure of the relationship is that we've

created long-term partnerships. of course in health care, long-term is five years. but the idea being that one of the barriers to physicians and hospitals being able to restructure the way they do things, that they live year to year, not knowing what their payment will look like. most payers make decisions about how they're doing to structure payment on a year-to-year basis. what we've done is say to providers who are willing to commit to a long-term, five-year contract, we'll guarantee their payment levels over that five years. which gives them the opportunity to think a lot more creatively about how they want to recognize the efforts within their system to change care. and the contract does, for both outpatient care and inpatient care, pay differently, according to the results of

that care. rather than just paying for each service that's provided. so this chart shows you the basic structure of the contract. the blue bar below the line establishes a budget per patient a global payment, that the provider is paid regardless of how many services they provide. they're no longer insented to do -- incented to do the m.r.i. or provide a service unless it's going to create the most effective outcome for the patient. and the provider is freed up to offer some services that might not be recognized or paid for in a traditional fee for service model. what we feel the global payment does is to get the insurer out of the way of doing mother may i utilization review. is that admission needed? that decision is left in the hands of the providers, and if

the admission to the hospital isn't needed and the providers can avoid the@@@@@@@@@ s'@ @ @ r c.p.i. much closer to the level of inflation that we're experiencing for other services in our economy. and then the final component, which is the component we're most excited about, is

recognizing quality. and so, for us, putting significant dollars behind recognizing those providers who offer better quality of services is really the most important part of this contract. we'll -- i'll show you the performance measures specifically in one minute, but one of the key questions we often get for those that lived through the capitation models of the 1990's is, haven't we done this before? and why is the alternative contract different? we certainly have experimented with capitation previously in this country and with some disastrous results for certain physicians and hospitals. we feel there are a number of differences that relate to how the budget is constructed and the fact that we are now able

to better predict the expected health care costs of members than we were 15 or 20 years ago. however, we do feel that we need to continue to look very carefully at how these budgets are constructed because there's still things to be learned and we obviously, we're protecting the providers from unexpected insurance risks. so the cost of a neonatal -- a baby who needs neonatal care or someone in a car accident, those things that aren't subject to better management, insurance problems. so we feel that the global payment of -- that can be done in 2009 is a different one and subject to better predictive science. so the -- i'm not sure if you can see these well on the screen, but we've established

performance measures that are nationally accepted, well recognized measures of care. these are not measures that were uniquely developed by blue cross, partially because we feel that providers have developed measures that they believe are important and that can be measured in a valid way. partially because we want these measures to be able to be adopted by other payers, we recognize that any single plan, blue cross of massachusetts covers about 30% to 35% of the people in our commonwealth and we know that even if all our members were in this arrangement, that it's very hard for a physician to completely restructure their practice for 3030%, 35%, even 50% of the patients. we want to collaborate with other plans, whether it's medicaid, medicare, the other commercial insurance plans in

our geography to adopt similar measures so that the physicians and hospitals can perform across a common set of measures for all the plans. we think that's going to be the best way to move the dial. not to have different measures for different plans and, you know, cause the physicians and hospitals to be trying to move their performance across a broad variety of measures, but to limit that pool. so these are measures both for the hospital and for outpatient care that fundamentally address the structure, the process, and the outcomes of care. the other thing we thought was exciting about these measures is that we initially provided the same weight, financially, in our incentive plan for all the measures, because we felt there wasn't any science around how to weight those measures differently. when we took the construct out

to the providers, the physicians said to us, don't you care a lot more about the outcomes than you do about the structure and the process? don't you care a lot more about whether a patient's gotten a hospital-acquired infection that was avoidable or a complication after surgery that's avoidable or that their blood sugars are at the right level than you do about some of the clinical process measures. we said, sure, but we know those are harder to achieve. the physicians said, why don't you triple weight those. weight those measures so if they're achieved, you get paid three times more than those measures that are structure and process. and that made a lot of sense to us because, like many other people, i've bought an exercise bike. that's the structure. i may have used my exercise bike. but unless i actually lose

weight, lower my blood pressure and i'm in better physical health, buying the bike isn't really enough. that's what physicians were saying to us. even if we put in the right structure and the right process if the outcome for the patient isn't achieved, then there's a problem. so we have triple weighted the outcome measures. and then finally, we've created a scale so that those physicians who achieve the highest rates of performance that are possible, so in other words, we're not setting the highest gates at a level that is not achieveable, will be paid significantly more. and our belief is that with this type of payment system, the incentives for the delivery system to restrubblingture, because the only reason for

payment reform is to allow providers to restructure care will enable some of these fundamental problems and access, including fundamental care, to be reimbursed appropriately and -- in terms of care and efficiency and can help solve the problems of access. >> thank you very much, deborah. [applause] >> as i said, we're going to turn now to a look at what government in massachusetts and the people who are subjected to it have done about access questions, and we're going to hear from sharon long. sharon is a senior fellow the urban institute health policy center here in town. he's a health economist of national reputation. she directs the urban institute's evaluation of the massachusetts reform initiative

as well as the massachusetts household insurance survey for the state government itself. she's also doing evaluation work on a number of other state reform efforts, so she has a perspective that's uniquely useful to trying to take a look at the reform measures in massachusetts. there's a health affairs article, the gold standard that sharon has written on massachusetts, and it's in your packets. there's an electronic version available through our website at health affairs that updates that paper. i commend it to you. sharon, i'm very pleased to have you with us, tell us a little about what's going on in massachusetts on the public side. >> thank you. my job is to give you an update on a real world health reform example. let me start by acknowledging the funders for this work, blue cross blue shield of

massachusetts foundation, and robert wood johnson foundation. i changed my slides a little bit, i took one of susan's slides, i want to give an update to what she mentioned. as you remember, it was to improve access to care, cover the uninsured and bend the health care cost curve. as we look at massachusetts, i'll go into more detail on, but massachusetts has significantly improved access to care. this was before implementing all the elements of health reform. before the minimum credible coverage standards were implemented and before the small businesses could buy into the program. significant gains there. in addition, this was before what some are calling round two of health reform in massachusetts which is, the state made the decision to address expansion in coverage

and access to care first and then turn to costs, and that's where the state is just beginning to now address the costs. substantial progress for the first two goals, just starting oven the third. the work i'm reporting on today is based on a survey in massachusetts, we did a baseline survey in fall of 2006, our prereform world, then we did follow-up surveys in fall of 2007 and fall of 2008 and we're working on funding for fall of 2009. we're looking at how insurance coverage, access, use, and affordability has changed as it's been implemented in the state. one limitation is that we're looking at changes over time so we capture health reform and other changes other time. in this world we capture the effects of the recession and the impact of rising health care cost as well. it's not a pure measure of the impact of health reform. what i would caution is those

two effect the recession and rising health care cost would dampen the health care reform. we're probably underestimates what the health care reform would have got if the economy had stayed stable and medical costs had stayed stable. let's look at the findings. the impact of reform on health insurance. this shows insurance coverage in fall of 2006, which is the yellow, fall of 2007, which is the blue, and fall of 2008, which is the purple. the first set of bars are the overall population, the second set is lower income adults, and the third set is higher income adults. lower income is 30% of poverty, the cutoff for our comcare program. there were significant increases across the overall population and the low income

group and high income group. for the low-income group, it was at 96%, nearly universal coverage in 2006. this compares to 80% in other state, well above what other states were seeing. most of the gains in insurance coverage were among low income adults. there you can see a gain from 76% coverage in fall of 2006, to 92% coverage in fall of 2008. a substantial gain over the three years of health insurance reform. i should note here, i'm not showing it in the slide but the increase in coverage in the state is both gains in public coverage and gains in employer-sponsored insurance coverage so we don't see crowdout of employer-sponsored insurance coverage. we attribute this to the individual mandate, we're seeing a takeup of coverage in the state. in addition to seeing gains in

insurance at a point of time we see gains in continuity of coverage. looking at this slide, which shows people who had coverage for the full 12 months, you can see substantial gain there is as well, so less cycling on and off of insurance coverage which should translate to more coverage over time. when we turn to look at access and youth, -- and use, we can say the gains of coverage have translated to gains in access and use. the first set of bars is having a usual source of care, people who have somebody they see when they're sick or need advice about their health. as you can see, we see an increase in that under health reform. the next two sets of bars are looking at doctor visits, any doctor visit and multiple doctor visits. again you see a gain in access. more people are seeing doctors and more people are having multiple doctor visits over time.

to place these in context, 83% of dulls in the u.s. have a usual source of care, compared to 92% in massachusetts, in terms of doctor visits, 78% of adults in the u.s. have a doctor visit and it's 85% in massachusetts. so we see better access to care in massachusetts and gains in access to care under health reform in the state. wuven limitation of the survey we've done is we can't identify people who gained insurance coverage because of health reform. all we have are three cross-sectional pictures. what we wanted to know was whether the gains in access just from obtaining insurance coverage or was it from other people in the state because there were changes in the minimal credible standards. we looked at people who had employer-sponsored coverage for the full year and with that population we see gains in access to care for that group as well. it looks like massachusetts reform effort expanded coverage

and improved what counts as coverage in the state, so there are quains on both fronts. consistent with that, we see @@$ for any reason. we looked at a need for doctor care, specialist care, medical test treatment and followup care, prescription drugs and dental care. i should note here, though

these look high in levels of unmet need if we look at a survey with data from other states, massachusetts tends to be lower than other states. massachusetts has lower levels of unmet needs but still has unmet needs in its population. what you see is strong reductions in unmet need in fall of 2007. and then some offsets of that in fall of 2008. a bit of a paradox. we saw increases in access to care, more people going to the doctor, more people with more doctor visits but more reported unmet need for care. it's clear that there was a push up in demand for care in the state and people had a harder time getting care. if you look at the sources of unmet need on the far right corner, it's specialist care and medical tests and followup care where we're seeing the unmet need as people are trying to get care. what it shows is that people -- as people are trying to get care under health reform in massachusetts, they were running up against the capacity of the provider supply and this

was an issue prior to reform that's become more of an issue as more people have care in the state. we added -- because we've seen some indication of this last year, we added a question to the survey this year to gather information about difficulties in obtaining care. i can look at this in 2008 but can't tell you how it changed over time. in the far right hand bar, one in five adults in massachusetts in 2008 reported difficulty in getting care either because the provider was not accepted new patients or was not accepting patients with their type of insurance coverage. more difficulty -- some difficulty finding providers. this was reported for both primary care and specialty care, it's not purely a specialty care phenomenon. it's more common along lower income dulls and adults with public coverage than among higher income adults and adults with higher coverage that may reflect the expansion of the coverage in massachusetts, a

large part of it is in the public programs, and that was within four plan, it was a narrow provider network that had an increase. we are seeing some difficulties getting access to care in the state. the next issue we looked at was affordability of care. health care cos in massachusetts are going up as they were in the rest of the country. that predates reform, it's not a function of reform. we're seeing some effects of that on reform. here, as in the access measures we saw gains in portability in the first year by fall of 2007 and then by fall of 2008, some loss of ground on those measures. so that we no longer see the significant gains or significant improvements in affordability over time. based on these findings, it does look like the trends in rising health care costs in the state are starting to undermine

some early gains in affordability under health reform. i just wanted to -- part of what massachusetts was able to achieve was bringing together disparty stake holders to come together and agree on a the re-form initiative. everybody gave a little bit, everybody got a little bit. that support was strong in 2006 when we re-form passed and that support has remained strong despite much press about the cost of reform and unexpected higher levels of enrollment relative to the numbers before. when we look at higher and lower income, it remains strong, gender, supportive, different ages are supportive. it's amazingly uniform across the state that supports -- support persists for the health reform initiative. let me recap what we know.

there were significant gains of insurance conching in the united states. there's no evidence that private insurance is being crowded oout. there were significant gains in access to care as people gained coverage and kept coverage for the full year. there was some significant improvements in affordability. despite the sesses, there were some indications of problems over the last year. there's some loss of the early gains in affordability as health care costs have continued to rise in the state and limits on provider supply with the increased demand for care created barriers to care for some people in the state. finally, as i mentioned earlier, health care cost is really round two of health care reform in the state. massachusetts is just beginning to really address health care costs. it's clear that the sustainability of health reform in the state will be a function of their ability to bend that cost curve, just as it will be at the national level. thank you. >> thank you very much.

thank you, sharon. we've come to the part of the program where you get a chance to ask questions. as i say, there are microphones you can go to to ask them, you fill out a written question on that green card and hold it up, someone will bring it forward. let me just start, if i can, sharon, with one of the pointses you were making about what the rere-forms are starting to do to access even as people are having more frequent doctor appointments. there is a -- in the materials, there's a survey taken in a number of cities that seemed to say that folks in boston were having more of a difficulty over time than those in most other places in the country in getting an appointment to see a physician. tell us what you think of that.

and whether it's something we have to watch out as we work on access more generally. >> i think there's actually other evidence from the massachusetts medical association that is consistent with that, that there has been kind of more demand for care and more -- with that more waits for care. if you look at kind of the timing of the increase in coverage in the state, it's clear, enrollment happened faster than the state expected. it's a good thing, people got coverage, but it happened within a relatively narrow set of networks. there was a strong increase in demand. what we think will happen over time we don't have the data, will be that some of the pent up demand will beesed as people get care and get followup care and the demand should be mitigated. what we're seeing is people have coverage for the full year, it's in the cycling in and out. as that happen we expect some pushback against that demand.

>> susan? >> i think this underscores why delivery system reform is such an important component of overall reform. we all know the phrase, you get what you paid for. what happens now doctors get paid, when you come in to see them. if you look at systems that have moved away from fee for service, like kaiser perm nene the, a cap tated system we published a study that looked at what happened when kaiser put in place secure email capability between patients and their physicians and lots of other interventions so you didn't necessarily have to come in to see your physician. what happened? visits dropped by 25%. people, it turns out, don't really want to get in the car and drive three hours to see their doctor, if they don't have to, nancy. i think you'd concur.

the delivery system has been frozen around the way we pay it. as we think of new ways to pay the system, the system will break up these frozen blocks of turgidity and do things like use email and do other kinds of things that will make it possible to have more encounters, if you will, with individual patients and free up capacity to be used in those directions as opposed to just in the old-fashioned visit. >> we have someone at the microphone. identify yourself and let me ask all of you who come to the microphone to be as brief as you can to allow us to get to as many questions as we possibly can. >> al, a.m. media, how do each of you see abortion access and coverage affecting overall health reform? >> you can see everyone's leaping to answer that

question. and if we have no takers i'm going to have whiff on it. nancy do you want to take a crack at that? >> i guess i don't think it's going to have -- i think that it's another set of services that some doctors or providers will perform and some will not, some payers will pay for and some will not, i suspect that it's just not an issue that's going to substantially tip this one way or the other, though it does have the potential, i guess, to elicit enough polarization that it could perhaps be used to either push in favor or push against reform. but i would think we should look at it as a service as opposed to something that ought to define whether this wins or loses.

>> david, georgetown medical school. massachusetts, to begin with, isen in a far more favorable state in terms of medical resources, both primary care physicians and specialists and substantial community health centers. were there to be an analogous reform through congress, address the work force issue because it appears on the two years that that's already a serious problem and a very favorable, probably among the most favorable situation we have in the nation. >> one comment, i agree with you that there's some aspects of massachusetts that are very favorable. we had a lower uninsured rate than other parts of the country and as you point out there's strong, academically, sources

for medical education in massachusetts. however, there's also some big challenges, for example the cost of living in massachusetts and the ability to maintain a lifestyle in massachusetts, and as nancy was saying, as a practicing physician there, earn enough to live there. so we feel that while there may be aspects of the experience in massachusetts that are easier to achieve in our state, there are probably some issues in other states that are going in the other direction. but i think what is going to be similar is that creating access to coverage will immediately bump into the significant problem of affordability and that fundamentally, though that affordability issue may vary a bit between states, i do think we all have that issue that the cost of care -- costs of care are grow manager rapidly than

what we can afford to cover. i think the work around how to restructure the care so that it's more affordable may be more similar across the states. does that answer your question? >> if you're going to speak, you should speak into the microphone, if you would, please. >> i sense from the preliminary data, the issue of actual access, more physicians not taking people, particularly lower income people, therefore a greater discrimination in who you see and apparently from back d -- backlog of people able to get access to care they wish. >> i think what massachusetts is trying to do is address those issues to provide incentives to see the patients in primary care settings and make adjust.

s susan was talking about. health care costs are high for the massachusetts than the rest of the country and are rising fastener massachusetts. so that piece is not the positive picture in massachusetts that other aspects are. >> just to underscore what nancy aid earlier, the main focus is primary care. it's clear from barbara's and others' work, primary care is correlated with the most cost effective, highest quality care. if you've got access to a primary care physician or primary care providers, you're going to have better care overall. that we know. we have this crazy system, as nancy said, go back to, you get what you pay for. we take the people in the system who provide the best, most reliable, high quality care and pay them the least. what's wrong with this picture? how did the system get this

way? then we take the people for whom, frankly, specialists, many of them are wonderful people if you know much about the@@@@@@@@xn@ @ @ @ @ @ @ @ @ social security why the gradual reforms will be important. >> i do think it's worth adding, though if you go back to the 1990's when managed care and capitation briefly held

sway, it may not be -- it will be every bit as painful as susan and the others have said, but it may not take as long as we think it will. during the 1990's a decade of reform in terms of how we paid for care we created tremendous numbers of new primary care training programs, filled them, probably the only time in my history, with the top students in the classes, it was the place to be because we thought we were going to change the way we paid for care and what we valued in this country. so if in fact reform can begin to show that there's a, going to be -- going to exist for a while, not just a couple of year, and that we're going to shift what we pay for, i think we'll in fact find many graduates who begin to look at primary care much faster, perhaps, than we had originally anticipated.

the 1990's is the evidence i have to look at. gary krystoferson, former d.o.s., congress. we built an inner city, public-private community health system in one of the largest cities of the united states. we learned what you need to produce healthy people and healthy communities. the approach to health reform to date has been slices. good slices like primary care, health insurance, this kind of thing. speak to me a little bit about what we really need, what's missing from the health reform discussion about if you really want to build healthy communities and make that happen. >> i think most of health policy experts and public health experts in particular

agree there isn't a whole lot of emphasis on public health in the reform bills. there's system. there's -- there's some. there's more focus on preventive care, etc., etc. but we look at some of the situations we face now, for example, the obesity crisis, we know we need to bring more to bear on those problems than just insurance coverage. i think that the whole issue of the so-called social and economic determinants of health that is to say your health status is to a large degree going to be determined not at all by your health care access and the treatment you get in the health care delivery system, it's going to be determined more by fundamental factors like your income level, did you grow up next to a toxic waste dump or not, all those kinds of things. that will be a work in progress. i think everybody agrees, the public health system in particular, is going to have to address much more assiduously in the years ahead. >> but again, to take a more

positive perspective, i said earlier i'm a pessimist, but i don't want to be. there are pieces, in at least the house bill that increase building infrastructure for public health. there are specific sections that address the value by attaching payment for things like smoking cessation, things that have not been included in an awful lot of payment mechanisms. so i think that perhaps if you add that to the concepts of patient centered medical homes and accountable systems, we will in fact have opportunities for a number of these communities to begin to grow up, if you will, and then because we're very competitive we may find that we can use those communities to encourage others. that the cost of care goes down if you have the infrastructure of public health and the primary care overlay and we begin to use those to put the

next layer. i don't think we'll get this all done in the first cut. but we've proven, as you said, that the we take it a slice at a time, we don't make any progress at all. >> i'd just make the observation that most frequently i've read criticism that these bills do too much or try to do too much, rather than that they don't try to do enough. there are at least a substantial minority in congress saying, maybe we're biting off more than we can chew. we have a whole raft of questions about -- why am i blanking on the nonsexist word for manpower -- >> work force. >> work force issues. let me attack a few of them, they are related. one of them has a pretty simple solution for the shortage, why not make medicare and medicaid acceptance required of all providers in order to close the access gap?

sounds like a reasonable idea, doesn't it? >> didn't massachusetts try that? >> would your massachusetts people like to address that? >> i'm not sure exactly where the question is coming from, physicians are required -- >> one of the ideas floating around as these bills started to get marked up was the idea of linking participation in medicare to participation in a public option, a public plan as a way of making sure that access for that group of people , presumably more the subsidized folks, would be relatively guaranteed since doctors and hospitals couldn't afford to write off medicare. as i recall, it was not met with unanimous approval. >> i'd say that's the

understatement of the day. >> that's perhaps the answer to the question. >> a fundamental issue here is, are you going to require providers to do certain things, number one. but also, what are you going to pay them. now in medicare, obviously, the federal government has leverage to control what physicians are going to be paid. that's what we've been talking about, some of the payment reforms that would basically make it more attractive for pry prie mare care physicians in particular to see medicare patients. on the medicaid side it's more complicated because medicaid is jointly run between the states and the federal government and jointly paid for between the states and -- between the federal government and localities. to raise rates in medicaid means the states have to go along with that as well, and the states are in a pretty injured state with their economic considerations and fiscal considerations. how we address that over time

will be an issue. in the house bill, the medicaid expansion that would take place would be entirely paid for by the federal government. that's an attempt to address this notion. but it's not utterly obvious that that is going to mean that payment rates get bumped up in medicaid. nancy can probably say more about how low medicaid's raids -- medicaid's rates really are. but that's a serious barrier. until that's addressed, a access for medicaid patients will be an issue. >> they oftentimes are as much as 30% of what medicare pays which is perceived in most places to be probably 80% of what private insurance pays. so now you're getting down to a fraction of the cost it takes to drive the process. i would probably say the best reason, though, ed implied, is that while physicians and other health care providers are not a big enough group to kill health

reform on their own, if they in fact are incensed enough to try to get all their patients opposed to a bill, they can in fact at least seriously disrupt the likelihood of passage and mandatory participation would probably be adequate to get that kind of activity going. >> and this one actually addresses the same question at a state level and initially it's directed at you, sharon. how have state government payments changed since 2006 to doctors and hospitals and how has it affected or how will it affect access in your opinion? >> one of the things massachusetts did was to raise medicaid payment rates for physicians and hospitals. they did address that.

they're not as high as i'm sure the doctors and hospitals would like to see them, but they were moving those up to address the capacity issue. and i think, you knowing one state that's done this, along the lines of the earlier question, is minnesota, which says if you want to participate in medicaid, you have to participate in the state government health insurance program. ways to tie them together to come into medicaid. >> this one addressed to both of you who are familiar with massachusetts' situation, were co-payments, or are co-payments and deductibles included in these insurance programs and have they been at snerd >> they are still included. >> that's not affected by the changes in your payment ex-personality, then? >> in the blue cross blue shield contract, we are applying that contract to our h.m.o. right now and employers and members can purchase different types of benefit packages but all of them

include some level of co-payment or dedubblettable in the product and what we want to do, as an earlier question addressed, is to start to introduce some alignment between the members and physicians so that lifestyle issues, members who are focused on maintaining their health, either throw smoking cessation, weight loss programs, etc., on the other side do get rewarded for that, in addition to having co-pames and dedubblettables for medical services. >> one thing the state did with minimum credible coverage, setting the floor of what counts as insurance in the state, was setting limits for the out of possibility costs could be for the year. there are some pushbacks on out of pocket costs and for people eligible under 150% of poverty, there aren't co-pays. there are some limits on -- aren't subject to co-pays. but there are some caps on how high they can be. preventive care is now for

everybody in the state, for the insurance to qualify it has to be outside the dedubblettable, so you've seen an increase of preventive care in the state. >> continuing on the same theme, this is addressed to dr. dickey, medpac proposed, that's the medicare payment advisory commission, proposed increasing primary care reimbursements and decreasing specialist reimbursements in medicare. many primary care providers objected to decreasing specialty reimbursements. what would your advice be to policymakers on this issue? >> well, i think that to the degree that there's a single bucket of medicare dollars to be used to reimburse providers, physicians and advanced practice nurses and others, the reality probably is that some of the adjustment, if we want

to attract more primary care is by adjusting it out of specialty payments. it may not be payment per service, it may be you reduce the numbers of specialty services which is part of that bending the cost curve many of us think will occur. so i'll get paid just as much for every coronary artery bypass i do, maybe i don't need to do as many of them if i follow evidence-based information. obviously, i would assume those primary care physicians who don't want to take a pay increase off the backs of their colleagues, assume that somebody will put additional dollars into the bucket and specialists continue to get paid at the rates they are and we'll raise the tide and if that's an option, we'll all go for that. none of us want to be divisive within our peer groups. i don't think that's an option.

i think we need to talk about the fact that the money that's in the system needs to actually either go to providing more care or somehow bend it so there's less money in the system suggest that we're going to have to take the dollars that are there and spread them around differently than we have. so it's nice that you want to take care of your colleagues, but i think the data says we need more primary care. >> ok. here's one that goes back to something that several of you have referenced, that is the importance of preventive care. the questioner states, 37 states currently require insurers to provide prostate cancer screening as a benefit. but then we'll lose that benefit in currently debated health bills because they are not recommended by the u.s. preventive services task force. how can we ensure access to these important measures? if i can add a second half of

that question, how do you judge what's an important measure if and what's -- what the bills have attempted to do is say, for that 50% that we have pretty good data, we ought to practice based on what the data sells -- tells us is good practice. for that 50% for which we do not have good data, we ought to be spending some of our research dollars to collect the data. one way to do that would be to

say for the 50% we don't have data, if blue cross is going to pay for it for you, you should be enrolled in a study so that three years or five years or seven years from now we'll be able to give you data that says it either helps to get this care or it doesn't help. and so we could then begin to say, at least for insurance purposes, for which a third party is going to pay for your care, we will pay for those things that appear to make a difference in your longevity, in your quality of life, in the timeliness of your recuperation, and then if you want to by those -- buy those things out of pocket for which there isn't good evidence but which either your physician or someone has convinced you you probably want to have it anyway, that's fine. you can always write a check for that. you just can't ask your insurance company to pay for it. but if we don't have the data, as we don't have for about half

or a little more than half of what we already do, we have to find a way to collect the data and -- so we'll know where to put those things. is that a fair description of comparative effectiveness? >> and just to say about the specific case of prostate cancer, it sounds like a slam dunk. you want a test that tells you you have it, you want to know sooner rather than later. it's not that simple. prostate cancer grows very, very, very slowly. the odds are in many individuals that they will die of something else, not the 3r0s tate cancer they have. we are only now beginning to discern which prostate cancers will grow fast and which will grow slowly. several years ago, a study was done of young men who died in vietnam and a lot of them had the early stages of prostate cancer. they weren't dead they weren't going to die of prostate cancer, they were probably

going to die of something else. you have to say, does the screening test show what i think it does? does it show i have prostate cancer or not, not me obviously, but a man. then what's the intervention have? does it kill the -- does the intervention kill the person? does it require excess surgery? does it make me impotent when it didn't need to make my impotent because i could have gone to a different surgeon or could have undertaken watchful waiting. once those things get done to people, you find out what they die of. you have to follow them and see if they die of prostate cancer or of something else. it's not clear that prostate cancer screening is always a slam dunk. it is clear that some people get treatment that they don't need and die of treatment that they didn't need for a disease that wasn't going to kill them.

so as nancy says, until we understand all of this, it really -- it comes down to, are you going to recommend we take our precious health care resources and spend money on them, or are we going to spend money on things we have some evidence, while we gather evidence to figure out whether we should be doing these other things or not. >> there was an article in the -- i'm sorry, i'm not sure of the source, there was an article about british health care coverage and my legal counsel for my academic health center came in and thought he was going to start a fight, i think, because he said, the brits have put a dollar figure on it. they decided if the cancer treatment costs more than, i'll get the numbers wrong, i apologize, but more than $20,000 and doesn't extend your life by at least 90 days, they're not going to pay for the care. so they began to say, we'll spend this much money for this

much longevity. and i said, you know, i'm not sure that's all bad. we have treatment interventions that cost tens of thousands of dollars that we can't demonstrate extend your life at all and being a cancer survivor, i can tell you some of those treatments might make whatever extension of life you get almost not worth it. fortunately for me, i'm hopefully cured, but -- so we are going to have to start asking difficult questions about which interventions we do, whether we do interventions for some groups and not others because different groups of people respond differently, but we should do it based on science. on having collected information from an adequate supply of people that we can then sit down with patients one-on-one and give them information in which to make intelligent choices. to do that, we'll probably move a lot of things we probably think of as routine care today

into experimental models where we begin to collect this information. and there will be those who immediately scream, you're rationing care. but the reality is that if we're giving you care that costs you, or more likely someone else money and doesn't improve your life, then we probably ought to save those dollars for something that could make a difference in your life or somebody else's. it's going to be a tough time, i think, as we begin to explain to people that this thing we think of as great science often doesn't have much science at all behind it. .

>> i ask you to thank you for thinking our panel for a very well the discussion. [applause] >> excellent. >> o kahlah thank you. --oh, and keep. -- thank >> " washington journal"

continues. host: we are joined by alexandra and philippe cousteau, behind the effort on the planet discovery, but green planet, the month of august as blue august, all about oceans and water issues. welcome to the program. alexandra, i first have to ask the question about the legacy of the cousteaus. you are the grandchildren of job cousteau cousteau cousteau cousteau.

what deal hope to have accomplished by the end of august? what do you want viewers to know? guest: blue august is an exciting initiative my brother and i are pleased and honored to be hosting. it is a full month of programming highlighting the challenges and issues and some of the solutions are around conserving water on this planet, both motions and fresh water. it is very exciting programming indeed. host: you both grew up around water all of your lives. where do things stand, in your opinion? focus on the oceans. how bad is it, where is their hope? guest: we are facing a lot of problems with respect to ocean conservation. you have to remember that oceans of the life-support system of this planet. we lost about 25% of global coral reefs. many of the large fish are reduced by 90%. scientists believe fisheries will collapse in the next 40

years if we continue our current behavior. climate change, melting ice caps. there is a lot of grim problems. i think one of the great messages and signs is we are having this discussion right now. we are having not only a whole month of television program but robust online initiative for blue august. it unprecedented to dedicate a whole month to these issues. i think and that can't, society is starting to change -- i think in that sense, society is starting to change. host: we will show a clip, a preview of what the series is about. the same thing i asked alexandra, what would you like viewers to take away at the end of this month that they don't know now or should know now? guest: certainly i hope the walk away with renewed appreciation for the oceans, understands how important are no matter how -- where we live. but one of the great things about blue august that planning

green offered online are easy things people can do to be part of the solution. hopefully they will understand the importance of the oceans and how each one of us can do good things to protect the ocean. host: alexandra, you are founder and president of blue legacy. guest: it is an organization that i started in the year 2008. our mission is to tell the story of our water planet and get water to be part of the discussion again. we just finished a 100-day journey around the world, going to all five continents and selling both freshwater and oceans stories. it so it has been very exciting. we have made over 40 short films that have been aired on line and we are moving forward with discussions about experts and planning expeditions. host: in "the wall street journal" about the typhoon heading china and the collapse

of a hotel in china. has this been made worse by climate change? guest: i think there is very little question about the fact that climates' is being exacerbated by climate change. oceans are the primary driver of our climate systems. the reason climate change is a problem is because what it is doing for oceans. storms are increasing. desertification and droughts. precipitation patterns are changing drastically the, leading to conflicts. host: "the new york times" report on the front page, climate change is seen as threat to security. one of the war game drills, they reported they looked at the impact of a flood in countries like india and and parts of asia, and neighboring countries.

guest: if you think about water as are most of will and life support system and the vehicle through which we will feel the impact of climate change, weather drought or desertification, floods, rising sea levels, melting glaciers, seasonality of rivers creag before they ran year round. all of that is absolutely going to change the world as we know it. host: with we'll get to your phone calls. we have folks waiting. i did want to give folks a look at what's blue august is about. >> the ocean needs our help. time is running out. >> people have heard about global warming for years but it is only the past five years that experts really understood that carbon dioxide is causing problems for the oceans as well. what is worrisome it has not been on the radar. >> in a few decades it will profoundly altered oceans chemistry, rapidly making the water more acidic. >> scientists have demonstrated

that if we continue to pollute as we are now, the ocean as said it will double by the end of the century. >> and we are already seeing the signs. >> we are seeing water off the coast of northern california as sick enough to start actually dissolving seashells. >> if the smallest things and oceans are affected by acidifvcation, andipples up the food web making the largest things even more endangers. >> we need to change. >> we've got the last decade in which weakened isn't about the problem. but it is very clear if we do not start to deal with that right now, with stern and cuts 2 emissions, we are going to condemn oceans to extremely uncertain future. >> we know how to solve all local and global problem, the question is, will we. host: how long did this take to prepare? guest: this whole month has been in preparation. multiple types of shows.

footage from the world premiere of the special next wednesday night at 10:30 a.m. on planet green called acid the levels have been drained so much. the footage your dad as i love to see on the show. i am also an uninsured americans so i am not pouring these pharmaceuticals and to blue springs and i am concerned about that impact and me on the

uninsured family. could you address -- are you addressing blue springs? guest: it is a beautiful place. it is sad, the changes that happen. i did a story for npr a few years ago. the development going into florida and our wasteful use of water, not just in florida but are around the country. we will not be covering that the specific month, though. host: philippe mention of the wasteful use of water. what are you advocating in terms of methods of yours can take for yes wasteful uses? guest: so many things that people can do. some of the easiest things, turning off awesome when brushing your teeth or shaving. using appliances when they are full. host: such as dishwasher. guest: washing machine geared watering your garden and evening instead of the heat of the day. using pool covers.

but for the purposes of blue august, this is summer, everybody is going to the beach. packing out what you back in and making sure you leave nothing behind. and even picking up trash and that might not be your own, but leaving the place better than where you found it. an old boy scout creed. st: you brought a demonstration of something -- i will put this underneath the camera. guest: this is this plantgreen challenge -- band the bags, butts, and models. planted grain.com -- using reusable bag, did not throw cigarette butts on the ground. they can surprisingly take decades and decades to biodegrade. when it gets into the ocean, turtles and other marine organizations -- organisms can eat it. and tried to recycle as many

plastic bottles as possible. there is a challenge on the web site and the book and up load their own content of photos and ideas, a lot of fun. host: 4 myers. bill. -- fort meyers. caller: environment lists try to scare us when there are just as many scientists who say they don't have enough information and find out that al gore's tried to fake everything and took movies from home computers and stuff just to antagonize it and they want to get this cap- and-trade. what are tax is going to do to help the environment? meanwhile china is the biggest polluter in the world and they told the environmental is to get lost because they have 4 billion people to feed. we've got to do something -- just use common sense. that is all we need. you can't scare people, as they say. host: thank you for the call.

guest: certainly would face challenges. a lot of points the caller made their but respect to china. it is not an excuse to not do something in this country because other countries are not doing enough. guest: and china only just out ranked the united states in emissions, very recent. we were ahead of the pack. guest: for a very long time, exactly. i would disagree that there is not a consensus on climate change, and i think that research and science is pretty clear that a vast majority, over 90% of the world's finances certainly disagree. they may -- certainly agree. they may disagree on but pays, but certainly a problem. host: north carolina, go ahead. caller: thank you so much for bringing this issue. i would like to make it, and about republicans.

they don't care anything about anything go along. just let them wait when they died and the water, and nothing is safe and we will say. i have a question for you. africa -- you tested oceans and five continents. africa and somalia -- have you tested it or do you have information and could be let us know what is true and not true and i appreciate it and thank you so much for democrats bringing this issue. thank you. guest: africa certainly has a lot of water issues. we did not go to somalia on this expedition. we went to botswana and south africa. i think it is fair to say that everywhere where we traveled and did research on water is an issue and conservation of this resources and better management practices is pretty much a universal need.

host: "the financial times" has a picture of the drought in india. the monsoon season delivering far less rain than anticipated. guest: i have to say, first of all, i think the worst thing that happens to the environment issue is it became a blue or red issue, it is not about republican and democrat, it is clean air and water. one out of four kids in the city has asthma. it is not a political issue. i would say that first. but i think you point out an issue with oceans changing, desertification, not just in india but places like africa, darfur is essentially a water crisis. host: we have never seen drought levels at these levels? you are talking about, but this perk -- picture is india. guest: india facing critical water issues, just weeks after we left india on the first part of the expedition, over 1000

farmers committed suicide because the drought that had ravaged their land made it impossible for them to make a living and they committed mass suicide. i think we are seeing increased severity water issues and is impacting communities. host: are their drought concerns of the u.s.? guest: absolutely. atlanta, two years ago -- guest: 6 weeks away from being out of order. guest: the leg that they depend on, six weeks before being a munhall -- the lake, that they depend on, six weeks before being a mudhole. the governor was praying for rain. when the practices have not been able to ensure water supplies we are looking at a series issue. host: virginia beach, good morning, on the republican line.

caller: or you folks today? the earth sustains us and we have to take care of it, but, you know, more people will take you seriously if you expose the biggest sources, of not only corruption but of pollution and that is the federal reserve and the stimulus -- 24-7 stimulus that they create bubbles with and all of this overbuilding. host: what is the biggest source of pollution in the u.s. and the world? guest: in terms of our water pollution, urban runoff is not a worse problem than industrial run off. we have a tendency to think water pollution comes primarily from big companies and corporations, but actually people who don't take care of what they put into their water shade and for toxic chemicals

down the drain and things like that is actually a much bigger problem. host: mission, dave on the independent line. caller: first time caller. you were talking about earlier in the show that you were showing, that things start with the smallest things in the ocean and then go on board. i watched a special on television where they were talking about plankton being one of the smallest creatures that everything feeds on. and there were talking about we were starting to lose the plankton and that kind of thing, and they were going to be feeding the plankton with iron oxide to try to get more plankton into the oceans to help everything survive. i wish you could make a comment, and i will take the answer of the air. guest: iron oxide, i have heard

that, dave, that theory if they use iron oxide it will increase plankton blooms. but there are a whole host of problems and we moved away of that kind of engineering of the environment. but you are right, the ocean is like land, it starts with the smallest creatures and goals of the food chain did i recently wrote an article about ocean -- it could lead to no more wells in the oceans. the new imagines ocean without whales? the small shelve creatures disappearing. little ones, they are out of sight but they should not be out of mind. host: define dead zones in the ocean. are there more now than there were 20 or 25 years ago? guest: of their over 400. host: what does that mean? guest: the gulf of mexico has one of the largest debtor zones, the result of tons of chemical fertilizers that float down the mississippi river into the gulf. it creates algae blooms that the

loan and then die and when they die they go to the bottom and a absorb the option in -- oxygen. and the summertime, of 8000 square miles where nothing can live. they told me about shrimp that jump out of the water into the beach and try to breed because there is no oxygen. host: abc and a couple of other news organizations reported on the great pacific ocean garbage patch. do you look at this in your series? guest: yes, a special looking at that. it is an area in the central pacific ocean where circular currents concentrate debris and it is roughly twice the size of texas, literally a soup of plastic, 95% are plastic. it is just a reminder that every single piece of plastic still exists that has ever been created. we had a saying at the nonprofit

i run, everything we do makes a difference. as my sister point of earlier, it is about reusing plastic bottles and not taking things for granted. no such thing as throwing away. it ends up somewhere. in this case, the central pacific. host: mich., france is on the democrat line. caller: what does overpopulation have to do with the pollution we have today? any answers on that? guest: that is a great question garet -- a great question. we are looking at a world where the population will continue to grow and we need to be ever more vigilant about how we manage the limited resources that we have from arable land, to walker, to clean air, to energy, so that the people who are coming next have the same quality of life and the same access to life that we have had and we have been blessed with.

that is increasingly a challenge that we all need to work together to solve. host: pr, from a sound one, on the international line. caller: my name is daniel. i want to congratulate you for having such great-grandparent's. he was absolutely great. since i was about seven i used to watch the shows every thursday night. he definitely planted a great seat. i live in port doh rico. -- i live in puerto rico, we are competing for one of the natural wonders of the world. this brief is so great -- reef is so great, it is becoming tammany -- contaminated. basically wasting what you see there. also on the south side we have a bay that is dying.

one of the two in the world. the only other one is in japan. nothing being done about it. the government doesn't care. i was wondering if there is some way someone could get involved, to kind of promote these efforts to protect our resources. otherwise we will be, like some predict, in a war that will be for water. family has brought some lands and argentina -- my family has bought some land in argentina where there are great lakes. some don't realize or don't care. care. for host: thank you for call. we will get some answers for you. guest: this is a story happening all over the world, water contamination and pollution. it is a shared resource, and it belongs to no one.

it is part of a problem because it is not monetized and people did not view it as they should. while we don't do any work in puerto outstanding organizations that do something and you'll be able to find organizations to support this. host: 1 oceanographer has said in his speeches that with the budget of nasa you can find noah -- guest: 1000 times, this is 1000 times larger than the budget for ocean exploration. we do love the good things from space exploration, but this is about healthy oceans and healthy water. host: i am sorry, go ahead. puerto rico, one not

not only depend on the government and organizations but there is a huge old for people to get involved in their communities and just learning about the issues and finding ways to get friends and families involved in taking action at the local level. it is one of the most powerful things out there for environmental conservation. we can never underestimate that. host: have a link to the blue august site on c-span.org. guest: and a lot of wonderful organizations like ocean conservancy that is part of the mission. host: green bay, wisconsin. bruce on the republican line. guest: good morning, sir, -- caller: good morning, sir, good morning, man. united states would -- if they would go back to paper instead of plastic, stop dealing with

countries -- how would that change the environment? guest: banning plastic bags would be a big step in the right direction for sure. whether are not going back to paper bags as an answer, because of still consumes energy -- as bill pointed out, we have a little back from the campaign, it is a reusable bag. that is what people eat should go back to. that is how we used to go shopping. but certainly applying pressure on countries to clean up their acts would be a tremendous step in the right direction. this country has an opportunity to take a leadership role, to retake a leader roll and we need to do that. guest: i was going to say, i don't see the downside to using recycled bags, to recycling plastic bottles, to try to limit the amount of waste we create, to six -- take simple steps. there is no downside. even if the skeptics were right

and it was not going to save the world and do all of these things that make our quality of life better, there is no downside to it. it is what people in the 1950's, and that is what people harken back to as an ideal time. they use recycled milk bottles, they used recycled back and they had much less waste. host: in your putting together this program, do you see areas around the world of hope where areas are being cleaned up? guest: absolutely. the one thing i noticed as i traveled around the world and talked about issues, from spiritual leaders to government ministers, to students and and people on the street, is that they all value water and they all see it as their source of life. it is the one thing that connects every single individual in this planet, is our need for water, both the oceans and on land. the level for commitment and activism i saw everywhere, from

people who live in grass huts and had little access to education, to some of the most educated and well known people in the world, that is the one thing everybody agrees on. and they all agree it needs to be protected and managed for today and for tomorrow. host: west virginia. good morning to jail. caller: i am retired coal miner , and our big issue is the mountaintop removal issue. i was curious as to whether or not you guys would do anything on your program on it. we have had over a million acres of one of the most their verse ecosystems and the world destroyed from a mountaintop removal mining. it heard over 12 million -- 12,000 miles of -- 52% of the streams in west virginia that are known to be or thought to be contaminated with heavy metals

and other things. we have acid drainage. over 150, what they call coal slurry impairment in west virginia. host: -- calling in. we just have a couple of minutes left. guest: i testified in front of congress on offshore drilling and nrg exploitation -- when you look at coal and these polluted cost of energy, we are not factoring into the true costs, the kilowatt hours. i encourage the committee to think there renewable energy is artificially expensive and non- renewable is artificially cheap. one out of four children out of new your city has asthma. and magic of the environmental degradation. there is a tremendous price we are not factoring into carbon-

based forms of fuel that is killing us and telling the resources we need to survive. last summer when gas prices were so expensive, people were screaming to, isn't it terrible. it is tough to live without gasoline but a lot harder to live without water, three days, that is it. i think you bring up a great point in terms of realizing the true cost of the exploitation of those kinds of resources. host: wisconsin on our independent line. caller: first, i want to thank you for c-span. i want to thank the two young people for being on the air. it is so important. i don't remember if it was discovery, national geographic or the history channel but they showed a program where countries -- several countries in the world where they are playing with our weather and putting some kind of gas pump up into the ozone layer and it is affecting the way in that gulf stream patterns and other

patterns, and it is influencing -- excuse me -- influencing our weather. and also, why can't governments all over the world outlaw plastic? it would create jobs and get rid of all of this crap all of our water? host of you address plastic -- but what about the issue of government controlling the weather or other efforts? guest: a lot of that is happening in china. i understand -- i think it is silver oxide that they are seeding the clouds with to actually cause rain. the jury is out i think on how well the technology works. as far as i understand, it is pretty local as far as the impact. it does not really change weather on a large regional or certainly not a national scale. guest: you know, we have a lot of projects in the works around the world to try to find

solutions to some of the problems that we have created, like seeding clouds were covering glaciers with an enormous part to prevent them from melting. -- with enormous tarps keep them from melting. but the best idea is prevention. that is something that, again, we all have a role. guest: isn't the singing, ounce of prevention is a pound of cure? host: road island, joe. caller: the real pollution is not really coming from the people, but rather through the government and through the people from planet gren blew the mines. host: on that note, i will give you a chance to promote your show. starting when? guest: blue august is happening all month long. all august is a series of programming, intelligent

intelligent and online. hopefully we can help to inspire people to think differently about the problems we're facing. and there are a couple of premieres next wednesday, a special with bob woodruff. guest: >> thank you for being with us this morning. >> thank you very much. >> this morning, andrew exum will talk about the political and security situation in afghanistan. linda douglass of the white house office of health reform will join us. then phil gordon on the challenges facing united states cities. then we will talk about the economy with gerald seib. "washington journal" begins every day at 7:00.

then a conversation with lawrence summers on retirement security. watch live coverage. >> now, a tribute to conservative political commentator and activist phyllis schlafly. the -- she was given the clare boothe luce lifetime achievement award at a national press club luncheon. this is about 50 minutes. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> good afternoon. you all can keep eating but we will go ahead and get started. thank you for joining us at the national press club. i am the director with the clare

boothe luce institute, to promote conservative women. we are here to honor one of the greatest conservative women, phyllis schlafly, for defense of traditional values. we promote women like this through our campus relocation program. to find out more, call 888-811 [unintelligible] or visit our website. and i would like to welcome michelle easton to present the award. [applause] >> thank you for joining us today at the national press

club. welcome to the c-span audience. today two have a special luncheon in honor of phyllis schlafly para we send a special thanks to mr. roger milliken in south carolina who made this event possible with a deft. he has been supporting the clare booth luce policy institute since our first year in 1993 and mr. milliken, let me thank you so much for changing in saving the lives of so many young women all over america with your support for our average to young women and promotion of america's great women conservative leaders like phyllis schlafly. now easier the clare booth luce policy institute presents one woman with a woman of the year award. we choose an extra nouri lady who has shown grace, leadership and dedication to advance the conservative principles but this year our recipient has such a

long amazing record that we felt women of the year just did not cover it. also today we are honored to present phyllis schlafly of with their first-ever clare booth luce lifetime achievement award. [applause] ms. schlafly first emerged on the national scene as a conservative leader back in 1964 with the publication of paribas selling book from a choice not an echo, the inside story of how american presidents are chosen. a few years later in 1972 she started a national pro-family organization now called eagle forum which he still heads today. in his tenure battle ms.

schlafly led the pro-family movement to defeat to the equal rights amendment in this constitutional amendment was a key legislative goal for the radical feminist movements and other leftists and would have greatly expanded the role of the federal government and the court's. mrs. schlafly has been inarticulate opponent of the radical feminists for decades and we can thank her a great measure for how inconsequential and these feminists are today. she has been on virtually every national television and talk show and has lectured or debated on more than 500 campuses, more than any other conservative leaders. she is a speaker in the clare booth luce policy program and will be featured in our 2010 great american conservative women calendar along with i was telling her earlier along with kerry pregame. [laughter]

in addition to a monthly newsletter called the phyllis schlafly report which is now in its 43 year mrs. schlafly has ordered 20 books and her books have coverage of subjects as varied as family and feminism, nuclear strategy, education, child car anb@@@@@ @ @ @ @ @ @ h >> her most recent book is "the supremacists." and she has a colun in wall street -- column wall street journal -- in the wall street journal and townhall.com and george magazine. she practices law in the supreme court and was chosen for to work on the bicentennial of

the u.s. constitution. she has testified before over issues, the whole range of issues -- education, national the offense, one policy and many more to work your way through college at washington university of st. louis and received a b.a. in 1944. he received her master's in government from harvard university in 1945 as hearing a jd interest dr. from her washington university law school in 1978. in 2008 to was awarded an honorary doctor of humane letters by washington university as a loess. she and her late husband of 44 years of the parents of six children and 14 grandchildren and in 1992 mrs. schlafly was named illinois mother of the year. the u.s. named one of the 10 most admired women in the world in a good housekeeping paul and

the world almanac major one of the 25 most influential women in america. mrs. schlafly will celebrate her 85th birthday this week and continues to be a tremendous force for the conservative movement. [applause] let me finish with a quota about mrs. schlafly, economist george gilder in his book, men and marriage: quote, when in the history of this era are seriously written, phyllis schlafly will take her place them on a tiny number of leaders who made a decisive and permanent difference. if she changed the political landscape of her country. and now it is my pleasure to present phyllis schlafly with

the clare booth luce policy institute lifetime achievement award. [applause] [applause] >> thank you so much, michele, and thing to for all your kind remarks andç in this award. i'm very honored to be here today. the last time i saw clare booth luce was when we attended a reception at the white house given by ronald reagan and she gave me a list back to my hotel in her limousine as he expressed yourself as very supportive of my work. so i'm proud of that and i also

want to thank roger milliken for hosting this luncheon. he certainly is one of the great patriots in our country who has been on the right side of every issue where many years. maybe even longer than i have. in i want to address my remarks today particularly to the young people because we need you. we need you to restore the america that we have known. if you need to find her place in and the conservative movement and i think maybe it was you learn from my life is a, first of all, that anybody can be a leader who, you can be later, iç was not born that way, i developed it and work that adds. and also whether grassroots can organize and take on all the powers that be and the feed them and that is a lesson.

[applause] you need to understand how destructive the feminist movement is. the movement that teaches young women that you are victims in the oppressive unjust society, that is just simply ridiculous. american women are the most fortunate people who ever lived on the face of the earth. and you need to not be propagandize against bat by a new women's studies or those -- don't waste your education dollar on any of those courses. an american women have always been fortunate. the feminist movement did not sought fly for women just in recent years. my mother that her college degree in 1928 followed by a graduate degree then. and i worked my way through college and went to my say a

non-traditional job. i will say bernard testing ammunition and the rogers ammunition plant in the world is a louis parent i tested 30 and 50 caliber ammunition with all the tests that the government needed to run before they accepted bids oral 42. accuracy, penetration, velocity, aircraft function. the tracer bullets implies, did they really go off. examining the misfires when they did not go off. and the course of the velocity. i worth half the time of midnight to aid in the morning and they ever have four to midnight and went to college in the morning and got through in three years and i don't know what college students do in college these days. [applause] but i work a 48 hour week. but i have been a volunteer in politics all my life into a

political science into my schedule and that is where the action is. as for in is going to depend what kind of a country we have been and you have to take your opportunities when they come along. now i guess some leaders are born but i was not born in vader. i grew up very shy. it's been a learning experience and i figure if i can two any of you can do it and we certainly are desperate for later today. at the present time you find in the conservative movement in this country is going to be depressed about the way things are going and i just want to remind you young people that we have been through other times of significant depression in by the conservative movement. of this is the way into less in the years preceding the goldwater nomination of 1964. that is why i wrote my book, a

choice not an echo come into this crime out of the north eastern establishment country club type of republican had been dictating our nominees. not in the middle west where i live in st. louis republican party was very -- today my think of it as almost right wing. we did not use the word conservative but it was genuine conservative and we were tired of these new yorkers telling guests who our nominee should be so i wrote this book to describe what went on and in previous republican national conventions. most of the people who have gone to the convention have never been to america what is a first-time experience for them and at that point i was a have -- housewife and a little town in illinois and, of course,

nobody is fine to publish a book by some of a lie that who had never published before. so i published it myself and is 03 million copies. [applause] and every week i need some public official who says i came into the conservative movement as a high schooler reading from a choice not an echo, because what it did was to show how this establishment republicans for forcing their views on us when we wanted to barry goldwater. and at any rate we got him nominated but we have a devastating defeat after that and conservatives went into another time of great depression. we did not think that we can ever a lacked a real conservative like barry goldwater. that is what made as well for richard nixon and we learned

that that was a bad idea. so that did not work out obviously. but those of us who were attending anti-communist movements through the 1960's when i was writing about the strategic missile defense and so forth, it never could have imagined the that the soviet union would collapse. we thought it would always be there and not only did we think fact of the whole intelligence apparatus in this country was convinced that the soviet union would be the great superpower and henry kissinger said one as the chief adviser for nixon and others that he thought his job was to negotiate the best second best place he could put the u.s. the has and these people believed the totalitarian government was more efficient, and get things done better and

could produce better well, now i know that is not so. it is the free market that produces better. better things, more conventions from a better quality of everything. and, of course, in the years after ronald reagan failed to get the nomination in 1976 he and others were traveling the country talking to little groups, redefine in their conservative image. in and he had a different view. he thought when it comes to dealing with the soviet union he had another message. we win, they lose and he made it work. [applause] and so despite our beliefs that we cannot win he did win, it was a big shock to a lot of us in

1980 when ronald reagan actually wind and then the same thing happened after clinton won in 1992. we cannot believe it feared a two years later we came and have the biggest republican victory and i think it was 40 years in '94. so that can happen in can but we need in the young people to become leaders and to take on an active role in the the whole political process. it is really find a. now you have got to be kind of tough to hear that because sometimes it gets a barack's as we saw just last week in one of these town hall meetings at the town hall meeting of a missouri congressman where the union dues came in and beat up a black conservative who was passing out fliers. that was his offense and if they did not like kathy idea that an african-american could actually

be conservative. but we know there are a lot of concern to test who are of all kinds emmy need to educate them and train them and stand up for them. and attend these town meetings and let the grass roots be heard because i believe that the grass roots in the all the powers that be. that is what we did with the whole rights amendment. it was a 10 year battle, we had everybody against the. richard nixon, gerald ford, jimmy carter, all the magazines, then 9 percent of the media, all of the calaveras who marched in protest of -- all of the money from all of the hollywood stars. we beat them all. [applause] of course, they have never been forgiven me for that but you can keep in touch through the

phyllis schlafly report. now in i guess i wrote 100 and out era but i write about a lot of other subjects to. and i hope you will enjoy being in the process that keeps our country great. and remember, those who laid upon the lord will rise up with wings like eagles and then they will run in not be weary and to ever be wary because the battle goes on year after. we need all of you young people to join us in the battle. thank you very much. [applause]

[applause]@@@@@@@@@ @ @ @ @ @ @ [applause] >> you are such a nice audience. and is not exactly that way on the college campus. >> but you are so good when you go, and you are always an inspiration. she will answer some questions because we have a little bit of time, and if you would not mind, line up and give your name and your affiliation and we will do some questions. >> you can even ask hostile questions. >> hi there, my name is maria and i am with the clare booth luce policy institute and have been inspired by your work since

before i was with institute but even more so as this is that we work with. still always going back to mrs. schlafly so they really love your work. i just wanted to ask you as a woman who has been involved so long in the trenches of hasty base but also raised a wonderful family and clearly have a strong faith, how did you back in the days when there wasn't as common and has accepted to be raising a family and in the trenches have did you balance that and you have any words of wisdom for the young women here now who are encouraged to put aside her family for career? >> you have to structure your life, to accommodate what is important to you. now i did not have any full-time job or in a paid job after i was married.

i spent about 25 years raising my six children and politics was my hobby. a lot of which was done on the telephone, by mail, a lot of it was pre internet, pretax machine. [laughter] and when iran for congress iran in districts where i never had to be done overnight. and i guess i am a workaholic. but it was fun in my husband was extremely supportive. he enjoyed when i was doing and it all kind of fit into gathered. one i would go on for some meaning whoever was the oldest one in the household was the one in charge. [laughter] but, of course, a full-time job is very difficult in that and back before you came on it used

to be that you're average of middle-class blue-collar guy could make enough to support a full-time homemaker in that same city in america that is slipping away from us with jobs going overseas sites you find out what you are most interested in and went to can develop as your particular space in the conservative side. but i was a marriage and family are certainly worth the top of the list remains and everything else had to blend in underneath it. >> kelsey budd, it seems to be overarching issue today is health care so i was wondering if you give us her thoughts and feelings about it. >> the healthcare bill is every bit as bad as the one we beat when hillary clinton was promoting her health care plan. it is a government takeover of a

tremendous health care industry. it is complete pain for abortion on demand any time in a place. we have recently learned about these counseling sessions they're going to give to the old people and basically they are sessions, why don't you hurry up and die, take a pain killer so you are costing us too much money. anybody who thinks that health care is going to cost less if the government runs it must believe in the tooth fairy. [laughter] it isn't going to happen. and then the idea of letting the government from all of our health care industry is simply unacceptable and i think we would be better off if we defeated a whole thing that is proposed and then if there is some particular revenues have --

remedies we can work and we can try that everything obama is promoting on health care industry is bad, it is government controlled. which is what he wants. he never had a real job before he bought and politics. he was a community organizer and this is a process of making people believe that they live in an unjust and discriminatory society and they should organize into protests and a man to take money away from the taxpayers. one of the big problems we face is that now about half of the people did not pay income tax so his plan is to take money away from the taxpayers and give it to the non taxpayers and i think we have to call him on every turn. i am hopeful that we can defeat the healthcare bill.

[applause] >> i'm eva molina, i go to amherst college. i want to know to think about the resurrection of seven equal rights amendment that they are talking about in resurrecting the and and for those of us who weren't around it can you, please, elaborate on what it was you did with the first equal rights amendment and? >> i didn't hear the last part of your question. >> and you elaborate on how it is that you defeated the equal rights amendment? >> it was debated for 10 years in this country, had completely their representation at the hearings. that was the only place where we had a 53d chance to get our message out in the u.s. defeated. the american people did not wanted. and, for example, illinois was

in the front line in it was voted on every year for 10 years and defeated. the attempt to resurrect its is i think principally a fund-raiser for the feminist movement. and they tell a lot of women who don't know any history that send your $25 and will put you in the constitution. of course, they don't tell them that men are not in the constitution so why should women be in the prosecution -- that isn't the way the constitution is written. you can't believe how many times i went to pot -- testified and my opponent is saying that they need and the equal rights amendment because we want to get rid of all men are created equal. i am sure you smart young people know that is not in the constitution, that is in the declaration of independence and fortunately we are not trying to amend the declaration of

independence. [laughter] if it had passed we would have had a same-sex marriage 25 years ago, and i testified in 41 state legislative hearings. there is no benefit to its. there was only one case where somebody came in and said our state has a state law that discriminates against women that era will remedy. their state had a lot less than that wives could not make homemade wine without their husbands' consent. [laughter] for this we need a constitutional amendment? you've got to be kidding. it had no other -- when i went on television and they would say they would make women think they weren't paid enough but, of course, in the employment laws are already sex neutral so it would do nothing in employment so they were never able to say that anything in the hearing is going to give you a raise or

help you with employment. however, the class and discriminatory law is the draft registration law which says that male citizens of age 18 must register and i have sons and daughters of that age when era was alive and my daughter thought this was the craziest thing. you're going to put this in the constitution and the first thing is you have to sign up for the draft like our brothers? it was an hon saleable proposition. we were just coming at of the vietnam war and, of course, you young people are fortunate to live in a post reagan era where you don't have the draft hanging over your head and so there are all kinds of bad things and then there were no benefits. they were trying every precut idea to bring it back, but you need to let your legislators know there is no benefit to have it wrong to anything good for

women, and it does a lot of bad things. thank you. >> my name is katie walker with american life league. i wanted to get your thoughts on the role of the pro-life movement within today's larger conservative movement in the fight against feminism. >> wealth, the pro-life movement is very essential in one of the things that's my represent my contribution to the movements, you see we have in the fiscal conservatives the 27 million of us who voted for barry goldwater in the 1960's and that was not enough to elect a president. .. in the social conservatives, many of whom had not been in politics before. they came here to help us defeat

the equal rights amendment, and because of abortion was becoming a national issue. and i talk them -- and i told them where the state capital was, and i got them there to help us, and i also talked all of the different religious denominations to work together on these issues, the issues that they cared about, like defeating equal rights and stopping abortion. and in 1980, ronald reagan was not elected because everyone was agreement -- was in agreement on everything, he put together a coalition of people who saw what they cared about, and the pro-life movement is essential to the conservative movement. absolutely essential.

we cannot do this without them. and so the republicans in name only, very mistaken in trying to get rid of the social conservatives guess we need to pro-lifers, and we are very proud of the republican national platform adopted a national convention. every time since roe v. wade has taken a strong pro-life position, and i believe always will. [applause] >> i am with the clare booth policy institute. we can all agree how important it is to have a model for young people these days. i wanted to hear your opinion on who in congress or who in the public sphere we should be looking to as leaders for the future. >> well, i am not ready to pick a candidate for president.

my opinion is that anybody who thinks he might be a candidate should travel the country and meet with small groups. and that is what ronald reagan did. he wasn't all that conservative when he started out. but listening to the people, he redefined his conservative views. and that is so essential. we can't wait until the primaries in iowa in 2012 to find out who these leaders are. you know, and the last time around john mccain who comes from arizona went up to iowa where they do meet with little groups. that is the primary system up there. and then he said and was quoted in "the new york times" as saying i didn't know integration with such a big issue. now, we can't afford to wait

until the primaries in iowa and new hampshire and south carolina in 2012. encourage everybody, and there are a lot of good people. congressman steve king, congressman michele bachmann, congressman tom price, just to name a few. and they are articulate defenders of the conservative position. and i urge them all to get out and travel the country. get out of washington and find out what the grassroots really want. go to some of these town hall meetings. [applause] >> i noticed that after in saint louis last week, that the senator from missouri, claire mccaskill, has announced that at her next town meeting she will not take any life questioned. she will only take a few written questions.

>> hello there i have a comment and two questions. first of all, the young lady who just preceded me, one of four daughters that i have, and i'd just like to thank you as a parent for being the role model that you have been for peeping like my daughters to look up to and see that it can be done. [applause] >> and the question i would like to put forth, it's more if you would just perhaps, it most recent appointment to the supreme court. and the supreme court in general appears to me, it is my sense, that over the years congress and the politicians are politicians.

but the real direction downhill, as i see it, has been a large impact of the decisions of our supreme court setting out what their opinion is for the rest of the country. >> well kaw it sounds like you read my book. because that is the theme of it. i trace most of the bad decisions by what i call supremacist judges because they do believe that they are supreme over the other branches of government and the will of the american people, can be traced to the erlewine court. and the whole line of cases, cases against religion, the cases to let the illegal aliens and, the cases against property

rights, the feminist cases and abortion cases, the case is signing international law. all of these things, bad decisions, what we call activist decisions stem from the lower untrimmed war in court because ward was a first run one to write that whatever the supreme court says is the supreme law of the land. and you all read the constitution. you know that is not true. the supreme law of the land is the constitution itself, and laws that are made in pursuance thereof, and all the laws are supposed to be made by the legislative body. now, i do urge you to get a whole picture, to answer your question, by looking and reading that book. but i will also point out that barack obama -- you know, the internet is so great to get

things that you might hav been buried in history. but he gave an interview on a chicago radio station a couple of years ago in which he said that the court didn't go far enough. all it did was change some of the law. but they didn't address the economic issue. they didn't transfer the wealth from the non-taxpayers to the taxpayer. and his motive is to find people with judges with empathy. that means the ones who really want to move the money around, just decide to lower laws. who cares what the law says. move the money around. and that is his purpose. and this is a very dangerous thing. and that's why with all of george bush's failures we can thank him for alito and roberts, and we can be worried about who

obama may appoint next, and be ready for a fight. and i will also mention for your four daughters, you give them a copy of my book, there are about a hundred of my acid under essays about feminism because it is really important for them to know what feminism is and how destructive and anti-marriage is. thank you. [applause] >> i have more of a comment than anything because i was part against the ra and that was a long time ago. but i just wanted to thank you and really how it was being on that committee that initiated me into the import of action and doing something. and i would just commend to

everybody, be a part of reform and read all her books. thank you. >> thank you. i appreciate that. [applause] >> well, yes, it is enjoyable. and it is more fun to win than lose, and we have had some defeats, but we have had some very significant victories. which when you get active, you learn about our other victories. it wasn't just the era. we have had a lot of other very significant victories. >> my name is rachel. i would first like to say it i have been a lifelong supporter of yours and you have inspired me and so may ways and i credit for you why i am here today. your gumption, you go out, a woman, you might sincerest

guidance. my question deals with your fight against era. i see today the importance of grassroots efforts, and i'm sure all of us conservatives are as worried as i am about the future. i really would like to know how was it that you took on the nation and change everyone's mind about equal rights amendment? how did you break through the brick walls of congress and gain medias attention? how did you do it and how can we work alongside you and do the same for a lot of the problems that we have going on today? keymac thank you for your kind words. well, there are a number of elements in that. i chose the battleground that we thought that battle on. in the battleground that i chose to fight on was the legal rights that women will lose if this is ever ratified. and so i showed how they would

lose the right to be exempt, and if they are in the militaries as volunteers they would lose the right to be exempt from combat. a wife would lose a right to be supported by her husband and have her children supported by her husband. these are discriminatory laws. that we would lose the right to legislate against same-sex marriage, that the era would transfer all laws about marriage, divorce, family law, child custody, everything to the federal level instead of the state level. and so i forced the other side into kind of dividing up to the report and come into the hearing and say they say so and so, and it isn't so. but that was the whole defensive game. it's like a football team that never goes over the 50-yard line. and they were not able to show

any affirmative case. so i would say that was a main thing. also, we had the committee in each state that was fighting it. we drink them, how to make the arguments. how to make them calmly and respectfully and truthfully, and not to say anything that was exaggerated, or not to use other arguments like it was caused by the un or some other argument like that. just stick to the legal arguments. and the one place where we got fair treatment was in the hearings, because your typical state legislators, when they hear about a bill, we need to hear from both sides. of course, the media doesn't think that way at all. the media were 99% against us. and it was pretty funny.

a lot of those shows that i was on, and so you will have to see -- i didn't speak a couple years ago called doing the impossible. it has some clips from some of those shows, and you will see how we handled it. and we just simply kept presenting the truth. and that was the thing the other side couldn't get a handle on. of course, the most frequent question i get is how you stand it when they are so ugly to you and say such nasty things. well, i just did not going to let those lobs ruin my day. [applause] >> thank you very much. >> griffin communications, and i go way back with bill as to when i was chairman in illinois and

phyllis was very, very supportive to us. at that time, phyllis, the hippies were the counterculture. and thus people wanted to have regular marriages and family. and everything kind of flipped in a way, you know, the hippies sort of won that battle because even some young people i know now are so conservative, they want to limit their family to one child. you know, they are kd of accepting maybe these homosexuals want to live together, this kind of thing. how do we go about sort of, you know, influencing this mentality, especially this homosexual marriage movement which seems to be on a steamroll. not only that, but also convincing our young people that children are a blessing and that every child that is born have something to contribute. there are so many scientists and

people, number 10 or number 11 in their family who aren't being born today. >> you have raised some very important points. i think it's important for young people to understand that it isn't just the gays who are pushing the same-sex marriage. it is the feminist movement to. and the feminist movement is really anti-marriage. you have an element of the libertarians that do not want the government to establish the rules for getting a marriage license. now, i believe we have to have the definition of marriage, that we have to have laws saying polygamy is a crime, bigamy is a crime, marrying a child is a crime, marrying a sibling is a crime. and i would point out that the

republican platform since the very first one in 1856 said that we are opposed to those twin relics of barbarism, slavery and polygamy. and the aclu is openly supporting polygamy because it goes along with this idea that marriage is just a private matter. now, marriage is not a private matter. the definition of marriage is society's way of dealing with these helpful little creatures who appear when men and women do what comes naturally. and somebody has to be responsible for taking care of them. and marriage should be the institution that isn't legally designated to take care of that child. and then you've also brought in, you have a population control movement, that these are the people who think the earth is more precious than people.

i mean, you can get rid of the people and just have, just have natural order here. know, people are good. and i am quite sure that god provides enough resources for whatever population this earth has. and so we need to identify the distractive miss of the feminist movement and where the anti-marriage and anti-children propaganda is coming from. and it isn't just the gays. thank you. >> elizabeth cordova with clare boothe luce. i was wondering if you could share one of your favorite experiences from being around college campuses. [laughter] >> most of the bad experiences were a number of years ago.

it has really gotten more civilized in the last few years. but there were several where a bomb set was planted so we had to change the location at the last minute. there was one where they all lit up marijuana as protests when i started to talk. there was another one where, when i started to speak, they were very noisy and raucous. and i shifted immediately to q&a and that didn't calm them down. and then the guy who invited me came up and said i see a spray paint can in the front row, let's get out of here. [laughter] >> so we left the platform. but i would say the most amazing was at the university of wisconsin, in madison, which may be the leftmost left wing college in the country. i apparently was the first conservative h