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to pay for increases in premiums. we are having trade-offs and what we would invest in and infrastructure education, and art. our public employees have not had raises and five years. it is challenging every sector of our economy. >> marilyn, it is not good to see that medicare costs are way down. that is not subject to the same market forces. it is no time to rest on our laurels. we have brookings, bipartisan policy center, they have pressed that now is the time to keep moving forward and not expect that trend will continue. to get ahead and keep moving down the path of cost control. >> from our perspective, the

blues after the economic downturn we did see a slowing in the growth of overall costs in medicine. what we believe, 18% of gdp is health care. the untaxed -- a prediction is that it will be increased by 2025. now is the time to impact that curve. we have seen a spike again. i agree, it is time to really focus on, after the implementation -- as part of the implementation of the affordable care act, to focus on cost. >> agreement on this? >> yes i think so. one of the things that we have seen that slows rate of growth in medicare in particular, we have a lot of baby boomers coming into the system right now. they are 65- 66-years-old.

15 years from now, they will be a lot older and meeting more services. people are worried about the long-term and doing something now to change the trajectory. >> i agree with everyone and what they have said. we need to be explicit about what we are tackling. if it comes by that we start talking about it and we get down to 3%, i know that we can do better. there are things at the plan level, the provider level getting patient engagement, we could do better. >> frederick is here from the nga. >> welcome. >> we are talking about costs. what is in the aca that is going to reduce costs? i would like to hear very briefly from each of you. what do you see that you think

holds the most promise to reduce costs? let's start with clifford. >> the big thing that we talked about was access. getting people to get the ability to get care. we have to focus beyond getting access. it is to the care that we are given. a lot of panelists talked about that. how do we give good quality care, how do we measure it? how do we make it efficient and decreasing the cost. this will involve public reporting, involving measures from a measure development different scales that we have been doing. it will involve data. data will be a big issue when technology comes in with the ehr and whatnot. it will be a collaborative effort of many parts of health care to get this underway. >> i would add to that, the provision within the aca that

establishes the center for medicare and medicaid innovation. it gave the secretary of hhs unprecedented authority to conduct projects in the medicare program, seeing that as a driver of health system change. it provided, for the first time, the secretary the authority to expand demonstrations in the medicare program if they control costs and result in improved quality of care. there are a lot of folks looking at the demonstrations and seeing some as more successful than others. this is really the start of the program at the start of those efforts. those can evolve, the secretary has the authority to change them. >> we will talk in greater detail about what cmmi is doing and all of those initiatives. >> i would just say that when you have 40 million to 50 million americans that are uninsured, we have a majority --

we have an opportunity to bring a majority of those into coverage. whether medicaid, a subsidized exchange, the commercial exchange additional medicare advantage members. we have an opportunity to put them in a managed care model that impacts long as initiatives, preventive care that is where you can begin to drive down costs. >> i agree with that. the focus on value and accountability is a real change. it is not an easy thing for institutions to adapt to. it is a change in health systems. it is a major cultural change in a hospital or the institution. that focus on accountability value, moving back towards the focus on the person at the center of care and working to get costs down while you keep quality up or improve quality that is a major improvement. the aca includes provisions that

include risk bearing aspects for hospitals. hospital acquired infections, readmissions all kinds of things. those, in combination, are significant. there is evidence that on the hospital acquired infections, some of those incentives are actually beginning to leave to people -- to lead to people focusing on those problems. the infection rate has come down in some cases. at least in one study i saw in florida. the hope is that that central theme will expand and that will keep moving over the next few years. >> elizabeth? >> i think we have quantified that up to 30% of what we spend on health care is not improving health. we can change how we deliver care and pay for care and reduce costs through delivery. everyone is talking about insurance coverage. the real opportunity is in the

delivery system change and payment reform that enables better care. patient centered medical homes are a great example. they are emerging around the country in part because of the aca and cmmi. we are having 20% reductions in hospital admissions because people are getting the right care in the right settings. we can improve care and reduce costs. >> i would pick up the same thing. we are seeing a real energizing on the state level for governors. a discussion about -- the possibility -- aca provides tools for governors. we see action around some of the new policies like value-based purchasing, enhance quality metrics, new payment models, aco's and bundle payments are new levers that governors can use to drive down costs and improve quality.

even more exciting than that is the energy that is at the state level. we are seeing governors thinking strategically about their entire system. and how do we drive towards a system that operates in a higher-quality, more efficient way. you see a lot of the same work going on in 25 states. it is about taking an honest, deep assessment of your health care system within your state and to determining where are the right places to drive towards higher-quality and more efficient care. i never level -- where i get the most excited --, governors are uniquely situated to pull levers to drive towards quality efficiency. they are thinking about their health care system and a classic market distortions like asymmetry of information monopoly. they are thinking about the levers they can pull to increase

supply or drive towards transparency. the conversation going on at the state level has become something much broader than even the new policies at the aca. it has become about how do we take an honest look at at the problems and distortions we have operating in our health care sector. >> that is an important point. health care reform cannot happen from washington. it will happen at the state regional, community level. working with physicians and health plans on changing how they deliver care. there is a momentum that has not been there. regional health improvement collaborative art wringing -- are bringing people together. there is momentum for change. >> when you think about bringing the different stakeholders, here we have "the national journal," a respected source of news, the

blue cross blue shield covering over 100 million people in the country, and the ama and advocacy group for physicians, coming together to have this discussion. we are seeing the opportunity to bring different groups from different perspectives together and figure out how to do this together. >> i could not agree more. everybody on the panel more or less agrees with the basic notion of value, person centered focused on bringing down costs and improving quality. you see reflected across the board in our organizations, at brookings we have an effort called bending the curve. everybody in town, that -- the bipartisan policy center everyone on the health policy side is in the same place on

this. now is the time to start moving away from -- moving towards models of care that and still more accountability and better quality. >> you see that across the political spectrum as well. i have been working in health policy for 25 years for democrats and republicans. there has always been a focus on the conservative side to control entitlements. you are seeing more they focus on the left. they realize that with increased coverage, there is more at stake and it is more important to control costs in the short term and change the trajectory so that in the long-term coverage is sustainable. >> you see that in the governors ' context as well. people say that there is no market for high cost low quality care. governors, more than anyone else feel the fiscal impact of

their health care programs, particularly medicaid, and are looking for ways to drive towards better outcomes. with a lower cost to the taxpayer. in the discussion about the migration of risk and payment information -- payment transformation. it holds a lot of promise. as we unleash the payments into something that allows providers to come created -- to become creative under a global payment. if you can save money, you will make money. that is a really powerful concept. we also know that there are some real market forces at work that are finding that migration. you have a lot of competition issues, you have markets where you have a lot of payers who are consolidated or providers that are consolidated, that can stand in the way as these things catching cold and transforming the system. you need an actor like a governor to step in and say we

need to push past some of these competition issues. an example -- data. everyone in the world things we need to have data flow so that providers can make the right choice at the right time for their patients. there is a lot of competition issues around data. why would two competing systems share data? you need a leader to step in and say that this is more important than the concerns of the market. if we hold hands and jumped in and everybody shares data, we are all on the same playing field. you need someone to get people to push back the concerns that have been holding us back. >> i would applaud the governors for that. i think it is being german by the private sector -- i think it is being driven by the private sector.

you have the systems that were built on the provider side that have incredible patient medical records. you have claims, other data on the payers side, government with very important data. there is efforts, not forced by government, but because these parties are saying how do we get the right information to the right clinician to put the person at the right point of care at the right time in the most efficient way? it is a combo between government, led by governors and the private sector. >> elizabeth, could you explain what you are involved in? >> the regional health improvement collaborative, there are about 40 of them, 32 of whom are my members. they are working on the ground. neutral conveners, nonprofits, to bring in the employers, government, patience, unions, to solve this and in -- in a

practical way. some of us have governors who will lead this, not everybody does. we are seeing private employers step up and say we cannot take this anymore. you are right. people want to pay for value. how do they know it? how do we know if we are getting high quality, a privately priced care -- oprah really priced care -- appropriately-priced care? that is another effort of the aca. >> let me ask you the question about data. are we getting the kind of data that we need? this conversation was supposed to go so that we talked about aco's -- as long as we are talking about data, has the aca set this up so that providers the community, the health care community now has all the data

it needs in the form that it needs? are we there? >> i run a number of databases at the american college of surgeons. from the cancer database to the american cancer society, to surgical outcomes database is -- databases. a quick answer is no, we are not. but we're getting there. we have to figure out how to get the correct data without a lot of resources nina. -- resources needed. that depends on what our vision is. once we put a metric out there. what we have found in health care, particularly in surgery. if you put a number out there, people will get it or get higher than it.

as soon as we put a metric out there and we start collecting good, believable data, believable for everyone on this panel, believable for the providers, that is where it will get better. it is predicated on whether we have the right metrics. then we have to collect the data well accurately. if it is not accurate, people will just leave the room. we have to do it officially -- efficiently. we do not want data from two years ago. we also have to make it risk- adjusted. so that the heterogeneity of plans, systems, and hospitals, will have a level playing field. a lot of things go into the data issue. as long as we identify and address these things, we are moving forward. >> when you hear from providers, if i am in an accountable payment model, i need to know

where i am on a real-time basis. so i can make the adjustments i need to make to hit my target. those targets are both financial, they are also quality. the development of quality measures, the ability to get agreement on them, to implement them quickly and in a way that people can report and know where you are. these are critical factors. this i would call an infrastructure that is necessary to move to the payment systems that you need to move to. >> in pennsylvania, the governor has led the charge. first neighbor -- first a democratic governor, now a republican governor. in putting the private and public money together to forming health information exchanges so everyone is sharing data. at a macro level, we are still struggling to put all this data together and have it tell a real-time story. there are beacons of home. if i can give one example.

we are at independence blue cross, co-owners in an entity which is a position portal for claims processing. it is getting into clinical things. we are finding is that the new company that is the majority owner, they are a health technology company. they have all the aco pulls -- acto to tools that a physician's office needs. you put that in a practice where people are using the data that is coming in and using the bull's-eye and engaging their members -- using the tools that are coming in and engaging their members. we are seeing an impact on costs because people are getting the right care at the right time. >> let's take a giant step back

and say where are we on data. we have the data systems that go along with a dash that do not communicate with each other. none of them connect, you could have five systems within a hospital. the system that rates prescriptions does not communicate with athe nicu. it is a terrible situation on data. as kevin pointed out -- as c atherine pointed out, is a bipartisan issue. one of the moments within the bush administration when there was a drive to release data. you just saw the obama administration push this forward in the aca. it kept the conversation moving forward. we have seen a paradigm shift

coming out of the administration where we move away from thinking about data as something that is being used to pay a claim or something like that. this is a tool that we have to unleash and allow people to utilize. there are a lot of smartphones with concerns about -- smart folks with concerns about getting at the pressures that stop data from flowing. there are two -- providers and payers are trying to serve their patients. they also have competitive pressures. we need to set up a system that allows them to move past the barriers with an understanding of what those pressures are. if you happen to live in an area that is heavily consolidated, you could have serious problems with getting data unleashed if people do not step in and try to

push past these market concerns. >> you cannot sugarcoat some of the challenges of getting people comfortable with sharing data in a competitive environment. it has been an advantage historically. you cannot ask physicians to manage risk without information. they cannot do it effectively. we have got to change how we think about data ownership. it is -- it must be about improving patient care. in the aca, there is a qualified entity certification program allowing communities to have access to data to use it for these reasons. >> one of the reasons that it is a sleeper program, it is called a section 10332. >> the transparency issue is a big issue. >> that is one of the

challenges. coming from federal policymakers, there are so many silos in our system to begin with. there is the data system then the financing people. there is not a way to bridge those easily. a federal policymaker's eyes start to glaze over when you talk about health i.t. and data. you have to think about how the data can be used to help consumers and other purchasers make decisions about what high- quality, cost-effective care is. that is where we need to make a jump. >> it can be done in a very hit the compliant -- a very hipaa- compliant way. it is more population-based. >> let's talk about some of the initiatives created in the aca. the cmmi, center for medicare

and medicaid innovation. it has $10 million over 10 years to "test innovative payments and service delivery models to reduce program expenditures while enhancing the quality of care. the -- care." there are many different varieties of initiatives that they are testing. most of them fall into the accountable care organization category or the patient centered medical home category. there are several bundled payments initiatives several varieties of others. i was hoping the panel could talk a little bit about -- let's start with the aco's. we have some recent evidence some findings come out on the acl -- on athe aco's that showed

some saving, some quality findings. what does this tell us. are the aco's the answers? we have aco's that are part of the initiative, we have aco's that are not part of the initiative. what part of the future do they hold? will they be a part of controlling costs? >> i think if aco's improve population growth, then great. they have encouraged people to have personal vision. i have talked to cardiologists who are talking to a nursing home operators because they are responsible for the continuum of care.

we are going in the right direction to thinking just the on -- to thinking beyond just the facility. i was struck by the reaction of the results to the pioneer. you saw a bunch of systems improve quality and reduce costs, typically that would be a great thing. i don't think we should understate the achievements in the field. >> it is going to take time, the economic model has to shift. if you look at it from a pair perspective, we have to be more comfortable sharing the management process, including data. on the provider side, it has got to be less about value and more about collaborating to get people to the right point of care. >> i agree. one of the things we called for an hour bending the curve report was to create a medicare copperheads of care organization. the bipartisan policy center have almost the same thing. -- was to create a medicare

conference of care organization. it is a fairly major adjustment. i went through a large academic organization that is one of the pioneers. it is quite remarkable. the results are a good more -- good deal more last half full. 40% of these pioneers saved money. all of them beat the industry benchmarks on quality. most of them are still there. is it done? no. we need data infrastructure groups so they know where they are on a real-time basis. we need quality measures. at the federal level one of the things we can do is look for everything we can do to move in this direction. whether it is in repairing the substantial -- the sgr system,

the sustainable growth rate system using that to move us forward. wherever we can we need to keep the ball rolling. >> i agree strongly. it is interesting. what a good concept. we are getting off this crazy treadmill. talk to any provider in the u.s. right now. they will tell you how fed up they are with the crazy treadmill of volume-based care. how many patients you see -- you know. is overwhelming. let's get away from that. let's create a global payment, let's share risk and allow providers to keep the patient healthy. if you do well, you make money. rely on the economic incentive. there are some real problems with aco's. you are talking about taking your system from fee for service

to a new system. you have to change your cost shock sure, - - your cost structuer. at a house -- your cost structu re. as a hospital, you have to create primary care and outpatient services that are more effective. a multispecialty group, you have to think about the composition of your group. you have tons of specialists who are doing their specialty work. under this new payment system, is there going to be volume for them? the health system, and the provider, they have a lot of changes they have to make to thrive under risk-based payments. the most important issue here is we have our cost structure right, we are building our delivery system, do we have enough contracts to make this work?

if we have 10% of our contracts under in -- under an aco, that will never create an economic incentive to move to quality. work to population health. what about 50%? that will probably not do it either. to swamp fief service economics and move -- to swamp fee for ser vice economics, you need most of your business coming in through risk-based. even in medicare, where you might have an mco, they are not paying frisk based, they are paying fee for service. we have got to give the aco's that are succeeding the ability to go fully at risk for most of their patients.

>> that will take time. >> here is the issue. it will take time across the country. the one thing that a lot of providers out there,, in particular health systems, are very scared of. is that one health system that really gets it right early, if they can get enough of its contracts at risk, they are going to be attractive -- going to be disruptive to that market. planted the seeds find the markets, tucson, chicago boston. allow those forward thinking providers that are embracing population health. my got diskmo -- my mom got discharged, she has a whole team around her.

we have to get multi-payer payment systems that support them and let them be a disruptive innovator in their market. >> dan is skeptical about how quickly this can happen. >> i agree. but we believe it is more difficult. we are seeing a lot of innovation on the large tertiary system level. we think the nexus point is in the physicians' office. it gets back to developing a relationship through a patient centered medical home. you are not a mill. you have a set number of appointments you have a set of appointments that would have gone to the emergency room but cannot come to the primary care office. you look at part -- at quality of care for the sheer numbers. if the physicians get it and understand that the payment model is based on meeting those

quality and efficiency standards, quality first, it will spread. >> i think we are all pretty much cautiously optimistic. this is a new paradigm of the way we are thinking about health. from the single provider to the system to the community. once we start to develop, i keep are being -- keep harping on the metrics. if we do not get measured, we think we are great. we need to get measured to see how we are doing. i don't think we have the right metrics to know if we are doing well. we are going to come up with these examples, my mom who has dementia, my brother who has diabetes. we actually do not know. we have a good jump on it. we need to do better in the infrastructure of collecting the

data. one more thing -- within, this is with insurgents -- within surgeons. and hospitals trying to improve surgical care. hospitals say if you are going to improve something, don't try surgery. what we have found is that a lot of things that happened the first year do not sustain the second year. or things that do not happen the first year, it takes more than one year to do. whether this is a hawthorne effect or a gentle slope. i think it is too early to tell. we need more metrics and sometime -- some time. >> i think we all are in agreement on this. the key point is that it is going to take time. our leaders came out with a report in april 2013.

they relied on accountable care organizations. we have learned a lot since the inception of aco's. there is concern in the current model but there are not enough incentives for providers or beneficiaries to move in that direction. it makes it difficult for certain provider groups to manage care when they do not have control or anyway of communicating with other providers. or even knowing where these beneficiaries are going. one of the things that our leaders recommend it was an attribution-based model -- a non-attribution-based model of accountable care organizations. recognizing that this will evolve over the next 10, 15, 20 years. giving medicare beneficiaries a choice of remaining in the existing fee for service

program, enrolling in an aco's or in an advantage plan. the approach that we took, in terms of incentives to beneficiaries, is a reduced medicare premium for going into some sort of organized system of care. and to providers, the ability to share in savings. at the same time, putting a freeze on the medicare fee for service. we fixed a bug -- we fixed the sgr. for those in fee for service you do not see the updates. but you have to give the secretary the authority to provide updates for fee for service based on various and -- on variation from region to region. this will not happen overnight. you have to give the secretary authority over time.

you ultimately have to support independent physicians' groups and provider groups generally. physicians give them the tools that they need, whether that is some sort of administrative assistance to help them move forward and to evolve a system -- to develop a system. >> in the current system, if people stay healthy, no one gets paid. we are asking positions to shoot themselves in the foot and actually i doing the right things for patients. if we change payments and go to global payments and there is room for innovation and improvement, that is our only way to enable the still every system reforms we are talking about. what the purchasers are concerned about, i am going to write you a blank check, how do i know jacob that goes back to the metrics. we have to have -- how do i know?

we have to have metrics. you get the metrics out there you could be more flexible. maybe it is a medical home, an aco, a community care team. >> does it not matter whether it is an aco or a patient cental medicare home, -- a patient centered care home, a bundled payment, are they all going to reduce costs equally? which should we be focusing on? what is showing the most promising evidence? >> they are all tools that can drive down costs and drive up quality. for us, we are looking for things that work. you mentioned changing the payment model. with our provider network, we have gone to individual clinicians a pay for performance model. it speaks to outcomes. the initial upfront payment is

held steady or reduced slightly, but we have found in our individual practices and health systems as a whole, if we do these things together because we are sharing the data. we are seeing data driven outcomes and the payment is enhanced. the thinking shifts from the traditional fee for service model. >> not everybody is ready to get on the escalator at the top. you can get on the middle, the bottom. all medicine in this country is local. when you have seen one health care market, you have seen one market. at different places, different providers, different levels, you need a variety of options to keep people moving. but you want to keep them all moving up the escalator. that is the point we all agree on.

keep people pushing up the ladder towards better, more accountable, more person focused care. lots of metrics, metrics are the key. we have a long way to go in terms of the infrastructure. >> throughout all of this, all of this restructuring, we have a lot of consolidation going on. does it matter who is in charge? who is managing whatever structure we have going on. i would like clifford to answer this. >> who is in charge? [laughter] >> i have to hold my tongue a little bit. as to what a lot of people are saying -- one thing, a lesson we have learned in visiting a bunch of hospitals is that you see one system, you see one hospital. it is hard to take something that works at the mauyyo clinic

and even go to the cleveland clinic. we did a collaborative, it did not work. it is going to be a different model. the system should support some structure but some individualization. as to who is in charge, that is part of the individualization. >> you have to be moving more of that payment system up that escalator, and the direction of more accountable care. >> i think it is less about who is in charge and more about every spoke of the wheel having a say in interest, and sharing the same information and care pathway. i know that is oversimplification. it is a complex system. that is what it is about everybody respecting each other's spoke on the wheel and coming together to move forward. >> that is perfectly said. that is the vision we all share.

we are working with governors on building these systems in their state. who should be in charge? i do not know. who is in charge? the economic incentive is in charge. should be a multi specialty group of physicians or a health system? health systems are consolidating, more thesis -- multi specialty groups, who is going to be dei director of risk -- the aggregator of risk and manage continuum of care. we have to make sure the option stay open. there is a strong incentive for systems to not change. i have an entire infrastructure built around fee for service. you have incentives for individual physicians who are specialists, that is also a powerful driver. if the health system migrates

faster and get really efficient, let's hope they succeed. if the multispecialty group gets it right really gets involved, they are going to be a terrific vantage point to impact the delivery of care. it is the economic incentive that is going to lead the way. whoever gets their cost structure right and is ready for the transition, those are the ones we want to win. >> before we open up for questions from the audience, one last question. there are a few economists talking about the formation of aco's and other arrangements that have, because of the invalidation that has come from that they are suggesting that this code and -- this could cause monopolies to form that could cause prices to increase

as opposed to decrease. is that possible? >> yes, it is possible. getting back to the point that has been made. if you are in one market, you are in one market. let's take pennsylvania. you take the five-county philadelphia region. there are any number of large respected teaching, tertiary institutions. university of handling a, children's hospital, temple university. there are community based hospitals either unaffiliated or affiliated. there are three or four very competent, commercial, government focused managed care entities. that environment is one where, if an aco is formed, it will be a tool for that institution to

drive down costs. but because of the competition i think it is one where a high cost -- a high-cost region where we can have an impact on cost. on the other side of the state you have got upmc, a full provider organization with a managed care entity. you have got a blue cross blue shield plan the two major health systems in the region. the choices are limited there. whenever choices are limited unless the entities focus on what is most important you have a possibility of cost escalating. it depends market by market. in our state, we have two examples that could not be further apart. >> economists see something in practice and ask if they -- if it can work in theory.

there is something real here. we are seeing the health systems coming together. suddenly, they are increasing their negotiating leverage with purchasers. there is a lot more consultative questions about -- more complicated questions about how do we know if that is worth that. we cannot have those conversations without transparency. the other question is if they save money, where does it go? back to the purchaser, to the patient, to the community? or is it just benefiting the same players? there are a lot more questions to ask. the risk is very real. we need to understand that epidemics -- the dynamics fully. >> you cannot get the benefits without more integration. figuring out how you make these systems accountable for that is a tough one. i am not an antitrust expert.

i think competition is good. >> let's take some questions from the audience. we have some mics, just raise your hand. if you could identify yourself. >> hi, i am dr. caroline. i would like to bring you to the exam room. i am concerned about payments for good outcomes. i can get your cholesterol down we have medications to get cholesterol on goal. i can go out and find people with bad cholesterols that i can fix. but then i have a patient with dementia another patient with brain cancer. we do not have anything good for either of those. but i can get their cholesterol down. if that is how i am being paid that is what i will do. those people need care.

what are we going to do about paying doctors to take care of the people who are really sick? >> that is a terrific question. this is one of the most exciting parts of the movement towards populist health -- population health. when you think about the problems some of these patients face, there may not be a good medical solution. but there are other solutions that they need that we are not paying for. we can save a ton of money if we start to open our minds and think about other ways we can help these folks. for example, at nga we are working with states on running super utilizer plans. finding those high-cost patients . the big lesson is -- i have a patient who was admitted 400 times in one year. on average, more than once a

day. that is $800 a day. what is -- it turns out, this guy had a lot of mental health issues not being true because we do not pay for it. he had some environmental health issues asthma, his environment was bad. substance abuse issues. if i go to a housing expert, a mental health expert and say we have $100 to spend. you can do anything you want $100 a day. they could change his entire life. and we just change -- saved about 90% of our spending. this is the kind of stuff -- it is really terrific. we get to reduce spending but improve the outcomes for constituents and patients. that is one of the most exciting

parts of population health. you see health systems talking for the first time ever, the postacute community. when has that happened? you see health systems talking to behavioral health systems. now that we are getting global payments, continental to us. how do you deal -- come talk to us. how do you deal with comorbid problems? >> it is also a cultural approach of collaboration. if we are punitive and it is a gotcha for physicians trying to the right thing, we are going to stop progress. we have to bring everyone at the same table and say we have a saying -- a shared goal. if we do this together and there are the right incentives and transparency, that collaborative approach is promising. >> i think what is going to be

important for this question especially is how we define what quality is. most of us look at it in outcomes. if you look at the components of quality, it is more than outcomes. we have gone through a lot of process measures, that was not sexy enough so we went to outcomes. it includes patient measures like patient experience, appropriateness measures, overuse or underused. we need to develop metrics that combine these components into what quality is and then incentivize it with value. we are going to have to get more of the whole pie of what quality is. >> i think of it in terms of primary care physicians that have an array of patients. very sick patients that you identified.

in some cases, the outcome is not going to be cut. it is going to be very costly to get to that end of the game. we have to make sure that, as a humane society, we focus on the best care for those individuals. then you have other patients that come to see the primary care physician that we can impact quality. we can put folks into preventative care initiatives that drive down costs. we are in a study with nyu around diabetes. we are trying to identify the diabetic that goes undiagnosed help and get them into a program. we are coming up with a product of -- a predictive model where a physician's office can see the traits pointing towards someone being a diabetic and began to put preventative measures in place. when you put those types of programs across the array.

it shows in a primary care office, you can nip costs and keep people healthier. that will lead to a larger pool to care for the high-cost, chronically ill situations. >> one in the front here. >> my name is becky. i was talking up -- you were talking about costs. the population that is going to be coming in, for mr. hilferty, into the exchanges. and that are going to be eligible for the subsidies. are they going to be different similar, how will they be with

respect to the medicaid population? you will have always people coming in who have not had access to health insurance. i am wondering how those costs are going to be. >> that is a great question. if you look at the impact that medicaid managed care has had -- whether it is state run with federal support or by the private sector. it has had a positive impact. you have taken folks who have access to character and emergency room, a -- who have access to care there and emergency room. they now have a card, they are part of a patient centered medical home, they have a system of support. if you look at the next tier, folks over 133% of poverty who will have access to a subsidy they are coming from an environment where they were not

insured. where they accessed care three and emergency room. they are much like the medicaid ovulation. managed -- the medicaid po pulation. it will be an opportunity to get them involved. that tier above medicaid folks that have some eligibility for a subsidy in the exchange, it will be their first time that they have had access to the capabilities of managed care. >> another question in the middle. >> hi, i am with the national

association of social workers. frederick, you have mentioned mental and behavioral health as an act that of all of us -- an aspect of all of this. i think it is a critical part of the quality of care and the quality of life. both frederick and others on the panel, i have heard nothing about metrics or measurements or taking this into account in considering quality. can you address this? >> i am glad we are making this point about the metrics. you said it perfectly. when people were looking at the aco, the notion was we are going to give you providers a lot of freedom, but we have to measure that. the measurement of the -- of

this is so important. the worst possible outcome -- if we are not measuring this right, we are creating a disincentive for providers to take the most vulnerable complex patients. that would be a travesty. that is the opposite of what we are trying to do. we have miles and miles to go on how we measure this appropriately. the problem we have had is, we have had data systems for fee for service. we do not have the data flowing so we can measure quality in a meaningful way. one of the proxies one of the reasons why the administration has pushed so hard for this, patient satisfaction. until we can get meaningful metrics in a broader way including behavioral health and substance abuse, we have to at least take the pulse of the patient. see if the patient is feeling that their needs are being addressed. patients never know if they are

getting good care, studies have shown. i don't think the score should be used to show that this is good or bad care. but it is at least a barometer until we get to the point we need to. >> two things. i agree with that. good -- mental health care is on parity in the affordable care act. it is an essential part of a benefit package. many people will have access to care they did not have before. that means a lot of adaptation for the institutions. when you get into any of these medical homes any physician i have talked to has told me that one of the first places they go is to figure out how to deal with the behavioral health component. depression is often a comorbidity with cancer,

congestive heart failure many chronic diseases. i think that this calls more attention to it. we have got to measure it better and hold people accountable for doing the right thing. i think that this emphasis on accountability brings people to focus on this issue in a way they did not before. >> until we have those measures, that is why it is so important to look at adequate risk adjustment. i know cms is doing work on this right now, particularly with the dual eligibles. until we have accurate measurements, we need to think about risk adjustment. >> >> i just wrote an op-ed letter to our "philadelphia inquirer" and about what we are doing with partnership. before i came onstage to to my retin-a mel from a social worker

that said great letter, you never mentioned behavioral health. we, as an entity, are trying to influence the provider community, influence our members at large about breaking down the old stigmas, the walls around seeking behavioral health treatment. the other piece of it is making sure that when we focus on innovation, we find innovative ways to reach folks who might be on the verge of a crisis situation and if we have the right way of touching them through the system, we will of wert it and get them the right level of behavioral and physical care they need. one company we have been involved with is one doc way. it uses secure cloud technology so that a psychiatrist/psychologist/social worker can handwrite face to face