time providing excellent customer service. that is a different paradigm than what we have operated on before. it is going to be an educational process, changing of a culture. it is a great system in that everybody at the cleveland clinic has one-year contracts. think about the large hospitals that have multiple private practitioners, or even inside the university system. even the universities do not take into account quality, oftentimes the promotion of the process. it is going to be a big change and there are going to be some bumps in the road. award peoplee to based on quality outcomes and holding costs. we have never been charged with doing that. we want to do as many big-volume cases that are high-reimbursable cases like heart and lung

transplants and big surgeries and things like that. one of the things i am concerned about is when you use volume, it is a metric for reimbursement, to have a level playing field to define what the quality parameters you are going to use. one of the things, especially with toby and bill and i, with cardiac surgery, and we saw this when the recording data -- ,eally reporting data came out the cases is west of the cleveland clinic. by design or by circumstance, maybe there will he be a de because of the tough cases and not offering services. >> so we know we need to get from one side to the other. i think everybody is clear we -- we are noto just paying for volume, we are paying for value. we need tohe where

go that is the problem, it is how do i make the economic model work from here to there. i am going to be taking on risk for quality and cost and so with fee- i am still for-service. how do you think about managing that transition economically? >> the good places are already along these whole wayne gretzky thing, skating to where the puck is going to be. how to manage chronic care outside of the hospital. i think there has to be an incentive put in place that changes the behavior of providers. we were speaking earlier. there has to be some shifts also to taking away some of the things that physicians have done and moving it down to extenders, whether it be nurse

practitioners, nurses, pharmacists, all working as a team. that incentive that drives the behavior. there was a recent "new england verifying that pay-for-performance works to change people's behavior. >> one of the things i hear from hospital leaders is that we have to be out of the business of being in the hospitals. we have two think about the whole patient across decisive care. you have been a leader in your private business and in the policy world of thinking about how do we build out a more robust continuum of care in different settings. help us think about what that means for the hospital. >> i think we have already touched on the big changes. i think the introductory comments -- people ask me all the time about the biggest

change we are undergoing. biggestto look at that changes for the hospitals of the future. the biggest changes that we are saying that can be transformative -- this shift in risk. with risk flows capital, flows money, flows investment, flows winners and losers. risk used to be, in the purview payersrnment, the big out there. but with obamacare, the acceleration, the shift was underway. the risk has shifted to the providers, the hospitals, the doctors, and eventually consumer. hospitals do not know how to manage risk. they have never had to do it. it has been did -- it has been the government, the big payers.

now it is the providers. to be theer is going new element, and the consumer is stay to be -- for you to competitive in this new world, you are going to have to focus consumer-based experiences, which go all the way from scheduling -- and toby went through some of them -- all the way through scheduling, how easy it is to see a physician or a say -- or 18, how long it takes, how you were treated. do you get laboratory tests before or after? what is the follow-up to keep you not in the hospital but out of the hospital, which means a hospital is no longer a structure, but it is an integrated system to keep people out of a high-cost to low-cost more appropriate side of care. i am optimistic about that. i think the government has made

a disaster over some very good principles in obamacare so far. trying to recover, but we will see. the leadership has been laid out worley, it has not been done well. but i am optimistic, and here is why. here is why it is so important with what you are talking about the next several days. technology today -- ipad did not exist three years ago. it did not exist. 94% of the people with telephones, 54% of people have smart telephones. the economically underserved have smart phones today. that empowerment of data -- information technology is not electronic health records. government pushed us that way. information technology, which will drive the innovation, which , is be consumer driven going to be automation, decision

, support, to make sure the right decisions are made by doctors and consumers. it is going to be the conductivity. it needs in investment to get the tentacles out there to do the outpatient or inpatient care. big data means data mining, the sort of stuff we cannot do before. competitive, you will have to have consumer-based experiences. the consumer is going to be technologically savvy in terms of prevention, care, treatment, and it will be driven through theuctivity, treatment, and data mining available. if we use those event -- if we use those effectively, you can stay competitive and the patients will have better outcomes. >> one of the ways consumers get to health-care is through the employer, and the payer indirectly. what doctors i can see, what hospitals i can access, and a

lot of the benefits structures are determined by employers. .hat is changing employers are getting increasingly impatient with the cost of health care, and the traditional benefits structures. where do you see the purchasing behavior driving the hospital business and the health care business. how will that change over time? given where employers are going? beenployers have always uncomfortable with the rate of inflation in health care, but they have always been willing to pay it. you can complain as much as you out asut it gives you an an employer. i have yet to meet an employer that will pay the 40% excise tax on a hip. let's establish a ceiling that employers are willing to pay. thesenator pointed out that

consumers will be exposed to more risk, and it will come in one form or another. when people see how much more they are going to pay, because they are only two ways -- have to either raise deductibles or out-of-pocket numbers. for every dollar you try to stay under in premium, you have to increase maximum exposure by participants to two -- to two dollars. $1000 is a huge exposure. that is huge exposure in uncollectible debt. the second side of it is if an employer does not do it by increasing exposure to participants, they will have to focus on narrower networks. the selection criteria has been make sure my doctor is in, my hospital is in. most of the networks that you look at around the country are established to include everybody. what we are starting to see on

the public exchanges, we start to see them move into the employer realm, are the specialized, narrow networks. the larger population says i want to give you access to the providers in the community, there is an uproar. but if you go to the uninsured population and say i will give this side of the community, that is a win for everyone. they will have access problems on their own, they go my to -- they might go to a less efficient provider. how do we do it smartly? there is a lot of moving dynamics now that the uninsured have care. that will be a big challenge for people. change ing on this the high deductible, there are some good things about that. ,t does bring the consumer in and the consumers we will be bringing in for obamacare to work is going to be a younger

population. so a deductible five years ago for most of your companies was probably $500, and now it is $2500 for most companies. so 30-year-olds will be forced today, mandated with deductibles of $2500, plus they will be paying $1000 or $1500, and they are the ones who will be pushing a button and saying i need an mri, i have to pay for it for the first time. because of my headache, because my physician says i will need it. it will cost $2500 at the center over here, $1200 over at andnhills, $300 next-door, the quality is the same on the same machines, and this button is telling me that. all of a sudden it will have a huge impact in terms of the power of the consumer, who is empowered with a bucket of money now, namely their own money, to

shop and the system will have to respond. that is going to eliminate waste, inefficiency. the money that is being spent today that does not go to better patient outcomes -- so to me that is very positive. the technology will allow and empower that consumer to make that decision. >> i think it is a really important trend. if you are a high-cost provider, and academic medical center or a specialty practice, you are probably at the high end of that pricing list on the app. in a transparent world, pricing will drop to some lower-level. that is revenue that is supporting a lot of other things .hat go on in medical centers i wonder from the perspective of the university of miami or tmc, how do you think about the challenge of the economic

pressure that that kind of transparency and consumerism puts on the sustainability of these important centers? >> it will put tremendous russia, particularly at the same time the government is reducing the amount of research money coming in. we have no place to cost shift to. the fact is we are going to have to live in the real world. we have to eliminate overhead and do all those things that other providers have to do. employer and a provider, so i see it on both sides. i don't think academic health centers will get off the hook. if we are 20% more expensive now, we have to bring it down to compete. i would point out that most people coming into medicare now have not had a lot of choice, so they are coming out of hmo's and narrower networks, so moving that -- moving medicare to a narrower network, moving medicare to less choice may not be as big a jump as some people would suggest.

people say a word about who cannot afford high deductibles. we have to be very careful about -- about pricey sensitivity for war people, for young people. we are bringing in young people, but also low income workers. with that group we have to be very sensitive about whether they will have real access to the health care system if they come in with high deductibles. as the be just as bad current system for them. at is what makes this so complicated. the different kinds of patients and people we are dealing with -- some of them can live in a world of high deductibles, and others we will have to be careful with or we will end up with lots of charity care or the in between. >> i would echo what president shall a lot -- president shalala

said. always cost centers, not profit centers. up of moreis made prestigious places through philanthropy, but you can never make up the overhead budget indirect costs coming back from grants. i am concerned, and there has always been this else the tension between the dean of the school of medicine, the ceo of a , how you support the academic mission. that is going to become even as time goes on. i agree that in order to be competitive, the inefficiencies with the academic medical centers, particularly hospitals -- and a lot of it has to do ' responsibilities,

ordering too many tests. we will have to fix that. my view is also optimistic about that. they're really good places will get this figured out, and it is starting to happen. toby shows that graft about the consortium. the federal academic medical centers have not been ranked as highly. they are focusing on that now in improving quality and cost. that will be the ratio we have to watch. >> we took 900 physicians out of our academic health center, and they were all administrative. we did what major corporations are doing and we looked at our staffing, and we protected the clinical side, but we took a whole layer of administrative recurring probably $40 million or $50 million in recurring costs. we had to do that because we are

seeing what is coming down the pike. we will have to be a more efficient organization. we are employers, too. high-costafford academic medicine as an institution. >> i think the academic health center -- you are both very involved there. for most people in the room, we all need to define our goals. the goals today are patient outcome. we have always said that, but now for the first time over the next five years, reimbursement will follow outcome of the patient over a continuum of care increasingly with bundling and reimbursement for one of your post transplant -- increasingly we are going to move to a more reimbursement. if you look at the hospital of tomorrow, it will be maximum outcome for -- maximize outcome

for existing sources or maybe less. yours is different because it is maximizing patient outcome, but you need to train the cardiac surgeons of the future and the primary care physicians of the future, and the nurses of the future, and the team-based approach. >> and research. >> and the third column is research. the $60 to justify billion of research or whatever it is going to be. and the role of training people who have a team-based approach. forget the way i was trained, the way bobby was trained. there is a team-based approach where nurses and social workers are elevated, responsible for more of the population than the individual. because by theff time they get out in the real world it is too late. for most people, the hospital of

tomorrow is not going to be miami or even cleveland clinic, but it is going to be the other 4000, 5000 hospitals that have to survive. that survival is going to be patient outcomes measured. that will be driven by primarily , twomer experiences hundred million people changing the system instead of a hospital ceo. >> do we need 500,000 hospitals in that world? >> probably not. trillion, has been $3 much of it is wasted. 5200-what ever hospitals out there in each trying to be a comprehensive hospital with as much marketing to attract patients through marketing? that is the old way but it is

pontiac and the airline's, in terms of delivery yources, how you go to get airline reservation. it is not the way financial services has gone today. that is going to be the difference. if you had appropriate allocation of resources, where every hospital did not have to offer all 20 different services, of course you do not need 500,000 hospitals. >> we have seen it in all of our communities, this arms race of if one hospital gets the latest, greatest m.r.i. scandal, -- mri scanner, and the others have to have it. i think that is going to be over. most hospitals in the country, they are in the low-single- digit's, and a lot of these hospitals are not going to be able to survive, nor should they. i do not think we need all of the hospitals to answer your question directly. but it will be difficult to make

if we are not part of the system. so we have to change the model of care, it sounds like. we are in agreement that we cannot deliver care with the same high-cost, so we have to figure out how to distribute the care, more team-based care, and so forth. but hang on a minute, where are all these deliverers of care going to come from? we will not have enough doctors, surely, to deliver all the primary care over the next 15 years. we do not have enough nurses today, and think about where demand is going. development, secretary shalala the numbers out there, 0 primary care doctors, too short of the next eight years. 40,000 doctors are needed today.

before, if obamacare is fully implemented. another 30 million people coming into the system who do not have insurance. when somebody comes into the system, their health care spending goes up 50% more than what they spend through the system. so 30 million people coming into a system that the 40,000 primary care physicians -- before you factor them coming into the session. donna, what do we do? [laughter] >> we start thinking about how people are trained and allow people to practice up to their training. the fact is that nurse practitioners can handle about 70% of the primary care. we should be using well-trained primary care doctors for more of the ambiguity, and this is the point that a bill -- that bill and everybody else has made.

we have to create teams, and that means physicians assistants and nurses and pharmacists and other care providers working as a team. we have to get over the hierarchy. we have to take on the scope of practice rules state by state if necessary, because that is what restrains us from creating these teams in many ways. we have to look at how people are trained and trained them better. the fact is we could handle this primary care if we could deal with the practice issues in almost all of the states. if we can overcome our reluctance -- we talk about teams as opposed to hierarchy. will we have to train people in the future? yes, but we have to use them up to the level of their training, and i think we can handle it. most people when they are brought into the system have to get health care one way or another.

people run to the doctor to get their physicals -- that can settle in with very good nurses and physicians assistants and the teams of caregivers to organize primary care, chronic care management to the end-of- life care. there are lots of things we can do if we can break down the barriers across the board. >> i think the policy is important, but it starts more fundamentally. doctors do not like teams. you have a patient coming into the door, the other surgeon steps in, and you have to fix it. and the teams that have to sit around listening in a collaborative way to other people, we just want to cut, fix some i get it done. >> you are talking about surgeons. >> in all seriousness, that is a transformation.

our professional ethics is not to be team-based. today,ctice of medicine medical schools are not trained. business school is trained with six people to address an issue, get an outcome. that is not the way doctors are trained. they probably are now with both of your centers, but they really are not trained very well to be a team-based approach where you are taking care of -- eight doctors are taking care of 5000 not 1000and patients. that is going to be, after my the thirdformation, big transformation is going to be team-based. we are not there yet, and everybody in every hospital needs to encourage it. you have to integrate social workers and integrate even the

epidemiologists and the presented -- the preventive medicine and the yoga specialists, and doctors do not like it. >> patient safety in the readmissions issues -- we have been forced to put teams together to drive down those costs so that we were not penalized. i happen to think in one sense we will change the culture through our training, through team training. we are doing more nursing schools, radical schools are doing more training of the groups together. but i also think we can drive this through economic incentive. i do not care how people are brought up. i care about whether there are incentives out there that can drive the change in behavior, and that is what we are going to have to do. pay thems do what you to do. the other thing that will happen is the game will shift from the inpatient side to the outpatient

side to the home. unless we are going to get our black bags and start doing house calls -- which i think is a pretty cool idea but we will probably not have tended do you it -- we probably will not have the game ist -- going to move into taking patients -- taking care of patients in the home. there are programs now to start to begin to train family members is more long-term care providers for chronically ill people. when patients go home with wounds, oftentimes the family member takes care and changes the bandage. they are a little freaked out by that at first, but they learn how to do it. i think the game will shift more to the outpatient home, trying to prevent readmissions will be a huge thing. >> let me come back to you for a second.

i am imagining all your non- health care employer clients listening to this conversation about a big line item on their budget and the people who provide that service. theeally have to figure out system say and how do we standardize and deliver a quality product. it is hard and we have never really been a 80 organization. we really just -- a data organization. will thelonger employer stick around for this story, rather than say i would rather not be around in this health care situation anymore? >> larger players are still relatively provided -- relatively committed to providing service. they do care about the health care population. but they also have the excise tax hanging over them.

employers are more inclined today than five or 10 years ago to partner with these hospitals and communities and try to figure out how do they create these alternative centers of care. overcoming the sense of it is only done to bring the cost down and educate the workforce that some of the things we are talking about actually improve the quality of care at the same time we are bringing the cost down. getting smarter about positioning that stuff will be the big difference. over the last 12 years, 60% --all employers 12 years ago now down to 50% -- that is before obamacare. if that is before obamacare, i think obamacare sets up the potential for a lot more

employers to get out of the business. because in the short term, obamacare, it is going to cost a lot of money. is out thereillion . an employer today can stop giving health insurance and give that employer a pocket of money that if the exchange system works, go out on an exchange and buy a good plan. it does not work long term because health care inflation goes up two percent faster than gdp over time. it's likely to return to that. i'm not sure -- that has gone from 60-50% with obamacare and i you have more money flowing in with a better system to choose from with people making up the 60 $5,000 subsidized by the government so potentially, another 10-15% of employers can get out of the business.

ok for the first two or three years but after four years, the individual probably because of high deductibles will not be able to sustain an inflation of two percent above gdp over time. i am a little more concerned about whether or not the employers -- i hope they stay in. consumers will drive the system but employers will drive the system because they do partner the way you said and they are putting wellness programs and their. establishing a culture of wellness and i think employers have a huge role to play. i think the hospitals of the future will partner with their community and community employers. supply health insurance because we want to be competitive for employees. the large ones will not get out but the small ones cannot the risk and there cost. they have tried to put exchanges together for the smaller employers and they have not been

able to keep the prices down. we'll obamacare do that in a way that will attract them? large and midsize employers will continue to provide health insurance to control costs because we've got to do it to attract employees, particularly those of us to recruit people outside our region. it becomes increasingly important. people ask you about that. >> as a follow-up -- i think it will shift a lot of the word and frankly, the accountability to the patients. they will have to assume some responsibility for their health. i think we are moving more away from secure to health care to prevent and keep people healthy. has an economic incentive, skin in the game, republicans will pay more attention to it. i am shocked about how much people will put into maintaining their car as opposed to

maintaining their old health. -- their own health. i think people will become more educated and go to the doctor, follow the blood pressure exercise, all the things we know that will provide good health but they will be responsible for it financially. >> we are going to have to good data for them. i can price a car or a repair because they are not on the link payments. they are not cost shifting within the hospital to make up for underpayment. the health care system and hospitals have to come a long way for consumers to be able to compare costs. example of bill's technology and being able to have that will happen and happen very quickly. people will shop but i still think they will shop on the quality over cost ratio but there has been a lot of work done on this. people will go for cost before

they go for quality. as a physician and someone who is an entrepreneur in this field, and do you think patients even know what quality is? >is it just service quality? be overriding thematic has got to be improving patient outcomes. for existing resources. how do you maximize the use of resources? it's innovative technology, connectivity, data mining, price transparency, listing prices more even though it is tough to do. that's the way you will have a smart consumer. on the first half of the equation, maximizing patient outcomes traditionally, we are measuring process measures. do you give a beta blocker or not?

place and we are only getting to the point of measuring true patient outcomes through measurement and part of that is patient satisfaction and patient engagement and how the patient perceives quality. we did not think of that until four or five years ago and now the patient will demand it. ultimately, the success of the hospital of the future is going to depend on patients coming in. if a patient comes in, it cannot be a patient engagement. it will have to be consumer engagement before they get second after they get sick with loyalty coming in. let me add one other thing. we don't have a lot of time but it comes back to the opening remarks. we spent twice as much as any country in the world. and survival is toh less, 26 and 30 compared

other countries which is discouraging and therefore we need - what? of tomorrow is outpatient care and what goes on at the home and it is palliative care. readmission is the surrogate but that's why you have to have these integrated systems where you can monitor the continuum of and manage the cost over time. people are hiring doctors and that will continue and bring those systems and. goodmes are not as therefore -- if you look at how 30% somebody lives -- it is genetic, 15% how rich you are, it's five percent the environment itself around you, it is 40% behavior. obesity, do we use our

seatbelts, do we smoke? that's not what anybody in this room has a store could been responsible for. the 15% of all of that is what we are, hospitals, doctors, nurses emma obamacare. you cannot fix the 15%. i don't care how efficient your hospital is. if you want to fit the -- fix the debt and the entitlement and the future of america and the american dream and the cost of not being able to invest in education unless we address the to, the hospital will have deal with a 40% of changing behavior and partnering with employers, and gauging technology that engages the consumer who is out there a year after hospitalization and are interested in monitoring their that tells you how much you sleep. that will have to be the purview of the hospital if you want to

make people live longer and lower the burden of disease and improve the health of the nation. >> the quality will be our responsibility. the heart surgeons four years have had our results president newspapers. you can all google it. surgeryety for thoracic calculator. 65-70 instances will say that based on your data and age and your family history, here is your chance of dying from this aortic valve replacement. here is your chance of being in the hospital for more than five days per year is your chance of stroke. then here are my personal results with patients like you. we have to demystify all that data and empower the consumers. many of the patients we saw

would come to us with this data already but we have to push that into the not as educated people through churches and social programs and schools and start early. we need a campaign were children aged know what their data is. is a very innovative program that high school students in the bay area came up get which is to go back and community project hours in the school. you went home and took him work to your parents to sit down and say you need to get online and do this survey so we know what your numbers are. what's your cholesterol what's your bmi? i think it will be an education process and many to push them about what quality really is. >> one last question -- you lead a large prestigious

institution and i have four kids at home and three of them are teenagers. i'm not asking for you to let them in but that would be great. [laughter] i spend a lot of time with health executives and doctors and others who face really tough challenges. the migration ahead of this industry is challenging and daunting. it is bimodal what i hear. one population says i'm glad i'm five years away from retiring and the other population says i can't wait to solve these problems. work inildren wanted to the hospital of tomorrow or wanted to work in healthcare in 10 years or if your students in miami were thinking of a future in healthcare, give us the optimistic case, why should they take on this challenge? >> it's a combination of things.

it's where the next adventure is. it's a major driver of our economy. there are huge amounts of new money going into it and we cannot keep doing it the way we've been doing it. who isoung person entrepreneurial and adventurous and wants a real challenge, there is going to be nothing like healthcare. it is where the action will be. it is where the excitement will be. that's what i say to my students. me in thanking our panelists for a great discussion. [applause] >> i want to introduce him. sorensen, ceo of siemens healthcare north america. siemens is a company at the forefront of the intersection of medical treatment and technology. is an esteemed neuroradiologist but before he joined siemens, he was a

professor of harvard medical school, codirector of the martinez center for biomedical imaging at mass. general hospital and a faculty member of the mit division of health sciences and technology. his own research and extensive political experience continue to inform the field today in work being done on stroke, cancer, and other health issues. it is and gentlemen, it's my pleasure to introduce greg sorenson. [applause] >> it was even with yellow tape. that's a little wrinkle to my remarks. i am going to share a few slides with you and thoughts, synthesizing what we have heard today and perhaps painting somewhat of a direction for the future. it's a real honor to be here with so many of my friends and colleagues from such rate institutions. this is the honor roll list. many of you are on it. in my new job, i have had a

chance to visit with all of these because they are all customers of ours. understandve come to the part of what the u.s. news & world report process does is it helps us learn from each other. it gives us aspiration, something we work toward, and it helps us compare best practices. this is not the case just for these top 18. there are also hundreds of other hospitals that are ranked that try to aspire to this level of accomplishment. a lot of good has come in that and it deserves some celebration. it's interesting to see how we pattern ourselves after each other. there is a lot of commonality amongst these top ranked hospitals. i've got some of the data here highlighted. 84% of them are large hospitals, 81% in cities of one million or many of them are teaching hospitals, many are part of a

chain. breedsbecause success success and would learn what works and we try to emulate each other and try to raise our level of accomplishment print i think that's great. there are a lot of good things that have come from that despite what we heard about the challenges of our infant mortality, in complex diseases, the united states is unparalleled. at cancer survival rates. we are number one in the world. this is true in disease after disease and all of you know that. none of you are flying to other countries to get your care someplace else. we see medical tourism coming to the united states for the top care, not to other countries. i think that's in part because of this process that we are talking about today that has focused us on the most complex illnesses, the most difficult itllenges and, in many ways, is the most interesting and has

attracted the brightest minds and some of the best capital. off, thataid specialization we have made, the investment, the leadership, many of the people in this room have developed the kinds of tools and systems that have provided this impressive result. here is some additional statistics that highlight the outcome of this focus -- we have a highly sophisticated workforce, much higher than the oece average in terms of specialization. in boston, if you are at a restaurant, and you your hand and say i need a pediatric neuroendocrinology is, you'll get four hands raised, no problem. there is a level of specialization across america that is the envy of the world. we have a tremendous life science industry that i think is the engine for a lot of our growth. there is biotech research here but also bio informatics,

devices, lots of really impressive biological thought processes emigrate here to the united states not because of the funding but the atmosphere. i was talking with the student i had a couple of weeks ago and she is from bought rain and spent time in my lab and has no gone to the uk -- she is from bahrain and she called it is not the same in the uk. there is a level of excitement in the united states and innovation. we put our money where our mouth is and it shows. formsws and things like of global recognition and i think that is wonderful. aboutwe are here to talk the hospital of tomorrow. here is where i think we can raise their aspirations and think about these complex soblems i think our panel

eloquently addressed. on this slide, i have outlined a form we use in our business to talk about a couple of different parameters at the same time. axis you will see spending, and the x axis, the spending. what would been focusing on in this honor roll hospital system is most complex care that we have chosen to rank yourselves on, that is the top right box labeled f. it is the most complicated patients and we spend a fair amount of money on them. what we are not talking about and when our aspiration is, is to look beyond the little box on the top right to bigger groups. that is where our healthcare spending is. how, if hard to imagine everybody in the center box, is trying to do things like f, that you can get a cost problem,

a focus on deployment, and the challenge and even some confusion in thinking whether it's about teamwork, patient engagement, prioritization of payment. then we have the healthy people we don't spend very much on that represent a pool that people move in and out of. slides, iare many to would like to talk about how we might spotlight areas to expand their focus. what might we think about and what are some ways that, as we try to move our country from focusing just on the most complex diseases and on a few things, to the many and where the big spending is? i have offered one slide each on five ideas. i want to run through them with you. each of these has some real potential to move the needle, as we say in business, for us and make an impact. let me go through them -- i

spent some of my lunch remarks talking about the value of early and accurate diagnosis. i would like to reemphasize that briefly. that nohave shown matter how you analyze this, diagnosis is an underrecognized and important problem. you can pick it up every week in the new england journal. there is always an article about improving diagnosis or it might be an article on diagnosis, the image of the week. we recognize, as physicians, that the diagnosis drives everything. that first 15 minutes with the patient sets all kinds of spending in motion. when we study medical errors, we agnostic errors are the most expensive, the most common, and the most deadly. if we can get diagnosis right and build incentives to get early and accurate diagnosis across the country, a lot of things would get better in our system.

thatember as a specialist frequently the patients transferred to our tertiary center came with the wrong diagnosis. getting the diagnosis right is hard and is never been a financial incentive to get it right. there has been plenty of ethical incentives. all positions want to do the right thing by their patients and are intrigued by the intellectual challenge of getting the right diagnosis. i think it's time for our system to incentivize in all the ways we know how to get an early and accurate diagnosis and i put some of the reasons how this could payoff and how it's not that expensive. we spend very little on diagnosis for some of the big impact with lab diagnostics, diagnostic errors based on autopsy studies and other data show that the errors are very common and have a huge impact and lots of lives lost. i was grateful to learn a few weeks ago that the iom has agreed as part of their study to focus on diagnostic errors and trying to improve them.

this -- ae of minority of this is the physician intelligence or mindset. it is a lot about systems, handoff of information from one part of the caregiving path to another, recordkeeping, duplication of results. we have not focused enough on this so i think that's real opportunity. another thing that is going to be important if we are going to attack the big box, as i call it, is thinking about getting high-quality care not just for the complex illnesses but for the routine things. boxhe left, i have put in a , the top 10 health conditions and the curve is the fraction of patients that fall into those 10 categories. it is about half the patients that have about 10 chronic conditions. could manage those 10 well, we would solve have her problem. a lot of what i'm learning in business is about trying the

get as much as you can with a focused effort and here are some areas we can focus. is interesting is dealing with these diseases is different than dealing with the complex diseases that u.s. news has previously ranked us so highly for doing. when you are trying to get a liver transplant, you don't care about parking. when you need your diabetes managed week in and week out or your levels are checked, things like parking, engagement, how hard it is to reach your doctor -- those things start to matter a lot and friction becomes important. that's not something our system is focused on. patient engagement, how much they care about their disease whether it is trying to convince or learnse a fit bit how to spell the names of their illnesses and opened a bottle caps -- this is a completely different realm, focusing on the

complex illnesses has allowed us to bypass. if we are going to move the needle on the majority of healthcare for americans, we have to start thinking about this. , have put some ideas here making the friction of the system a lot easier to deal with and focusing on that 40%, the behavioral modifications. that's a different kind of healthcare provision but it is actually very feasible and i believe that, just as we tackle many of these challenging problems with elegy and the systems we build, if we focus on this as a nation and as a system, we can improve these things as well. third of my five, integrating our care. that thefied to hear panel talked about this so much. we need to work as teams. we need to find ways on the same illnesses on the left how to figure out how to coordinate the care amongst the team members. we need to use all the skills of all the members of the team.

it's great to see that we are starting to build it systems to facilitate this but it will be a mindset change, cultural change. eitherf us who have worked with physicians know there is a definite hierarchy and those hierarchies get in the way. but i fly aplace lot these days. people ask me where i live and i say seat 11c. on ae never gotten on plane and thought if i got one of the top 10 pilots in the country. of the top 10 doctors and the reason is teamwork. you can build a system that delivers consistent high quality if you can build teams. i think we can learn a lot in the medical profession. the last two ideas are both about variation. we have heard over and over how we as a country have failed when we compared to our peers in terms of overall achievement for

the amount of money we spend on that's true. it's not uniform. as this graph shows, if you live in fairfax, virginia or marin, california, uf as high a life expectancy is anywhere in the world. whereas, if you live in tunica, mississippi, you are worse off than if you were in algeria or bangladesh. why is that? why do we tolerate that? we've got to figure that out. there is not easy answers to that and it's been a problem for decades. we have mechanisms to start addressing this. if we are going to start doing these things, we have to look at these things. we have to think about not just the top small fraction of the most complex cases but the broad routine care that we get day in and day out and geographically

distributed. finally, let's talk about price and costs. costs and value are all tied together. value is outcome divided by cost. if we're going to see was variability and outcome and we have variability of prices, it's pretty straightforward to see how we can have huge variations in what we see in our performance and we need to figure out why that's happening and try to reduce it. i was fascinated to see these graphs on the left of the cost spent per hospital day across different countries and across the u.s.. the 25th percentile of the u.s. is not that much more than other advanced countries. it's the 95th percentile that kills the spirit what is going on there? how can we start to get some transparency into that and understand it and reward the right outcomes? right, procedures on the

the means are not necessarily would kill us although they get the headlines. it is these outliers. maybe there are good reasons for those outliers but it is hard to believe that those outliers were there for good reasons all the time. if we scrutinize this and bring some transparency into pricing, something that is shockingly absent in modern medicine, i think we will be able to attack this as well. those were my five. i think if we have a chance to think through those that we will have a chance to move the needle on the majority of our system. with that, i will forward to chatting with you at the break. it's time for us to find our ambition. what is it we want to do? careust the best medical for the best patient but find a way also to reword high performers in the community. in my management meetings, i like to say let's catch people doing things right and that's

one of the great things that the u.s. news reporting team does is it finds what people are doing things right and mentions them and highlights them. finally, on a personal note, in my new job, i've had a chance to visit not only many hospitals around the country but also because siemens is in 190 countries, lots of places around the world. there is no place like america when it comes to healthcare. our lowest and hospitals are better equipped than some of the best hospitals anywhere else in the world. it's not a matter of equipment, it's not a matter of training, it's a matter of mindsets and a matter of what we choose to prioritize. i am grateful to have the opportunity to be here with you and find our ambition together and raise that and move things to the next level. thanks very much for your attention. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> in a moment, today's

"washington journal." this morning, the head of medicare and medicaid services will take questions about problems with the healthcare website. tavenner will be live at 10:00 he stern. --n international law voters in a number of states go to the polls today. tonight we will have live election results in the virginia heaven or and new jersey governor races. coming up this hour, we'll talk of the humanulton rights campaign about legislation that would ban work as discrimination based on sexual orientation or gender identity. the senate voted to move the bill forward yesterday. then we will have a representative from the latino coalition discussing the recent

shutdown and immigration reform and later, look at the history and role that third parties have in american politics. college officer david gillespie. -- college professor david gillespie. ♪ good morning, the senate voted to add fancy non- employment discrimination act. a final boat reportedly is expected this week. will discuss problems on healthcare voters in new jersey and virginia go to the polls today we will discuss the gubernatorial races but we would like to use them to discuss specifically your governor on this election day.