problem is, that's the first question, i happen to think. then what you have to do, where it has succeeded -- california is an example, arizona's an example, iowa where you bring competition back in. >> referenda. >> you got to basically take the state legislators out and put it into a court/nonpartisan analysis and that's what i would do. >> before we go, because i see you have your paper there, barney. i'm going to tee this up for you. >> thank you it. >> you want me to tee it up for you or you just go? >> you tee it up. >> is this going to the floor? >> no, i -- >> you can't go to the floor anymore. >> i can go to the floor but i can't talk so the hell with that. >> you were about to release a paper. >> it is an official comment on regulation before the agencies that are in charge of the statute with dealing with risk retention in residential

mortgages. >> that is going on today? >> the deadline is tomorrow. in the legislation, we band the bad kind of mortgages. they said i was keeping poor people from buying houses in subprime was fine. that is exactly right. you can read it. >> es copies for everybody. >> secondly, to the great bulk of mortgages, they were qualified mortgages. those mortgages, you would be able to secure them, but we asked for risk retention. five percent of the risk would have to be retained. that would incentivize them not to provide junk. because of senators, democrats, listening to people in the

mortgage industry, would put in a qualified residential mortgage, stupidly confusing. those mortgages were supposed to \those mortgages were supposed to be a supersafe category to securitize. to my dismay, the major proposal of the five regulators is to convince -- to combine the two, the other you can make without risk retention of any case. you heard that before. this is been the single biggest cause of the problem. i am hoping that they can be dissuaded and have risk retention as a rule of argument. they don't know how to make mortgages without risk retention. it apparently means no mortgages were made in america before 1980

when i came in. >> we are going to leave it there. this is been a remarkable three. thank you for the conversation and the questions. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> on the next washington journal, discussing last week's virginia governor race. our guest is matt lewis. after that, rob richie with the group "fair vote." he talks about the gridlock on capitol hill. later, a conversation on u.s. surveillance abroad, and how it is affecting diplomacy. the council on foreign relations joins us. we will look for your comments by phone, e-mail, and twitter. washington journal is live every

day at 7:00 on c-span. >> a senate hearing on wildfire prevention. how they have paralyzed impacted hospitals and quality care for patients. this is 45 minutes.

>> before i get to the topic at hand, i didn't want to miss the opportunity given i'm sitting next to someone who could not be better positioned to give us some thoughts as to how things are going with the moment occasion of the affordable care act. leader of a large academic ads -- institution, i wonder if you would give a grade to the implementation. >> i'm glad i am a cardiologist. it has been very tough. if we not to do anything, when -- we know how to do software. to see whether this is going to rollout, which i think that it is look at the states they're doing it themselves. they are ready have the platform. they're registering hundreds of thousands people for medicaid. the ones that are running their own exchanges have them up and

going for the most part. we do not have enough of them that are running their own exchanges are registering people on medicaid. i think we have enough time that we are going to get it right. we must have everybody enrolled. there is no way that we are going to be able to continue the cost shifting that has been going on our we are going to be will to deliver the things we have talked about unless everybody has insurance. it has to work. the technical problems are just that. technical problems. i haven't heard anyone say that they are designed problems. we know we have large numbers of uninsured. we know we have to get insurance. we know some of the need to be subsidized at the end of the day. we are going to have to get that done. i think there is enough time to do it by march 1.

>> do not know if anyone wants to -- i will just turn attention away from the hot topic of the day. an interesting thing in the post this week in, it was an article about implementation of the whole affordable care act. they cited a letter that david cutler sent to the administration early on after the law passed. it was interesting to me that one of the things that cited was not enough attention to provider engagement and getting the provider community bought into all of the changes ever going to have to take place. you lead one of the largest provider organizations in the country. if you think about the transition ahead, and making the changes that will be needed, how do you think about those challenges question mark how we manage to get from one side of the river to the other?

anyway that allows us to continue to bring in great care? >> i would amplify about the implementation so forth. it is a relief. we have to be patient. we will get everyone it needs signed up. living this new cycle and instant gratification by everyone, we are all appear with our cell phones and blackberries, and we need instant gratification now. big about when medicare was introduced. i think we have to be patient with that. this is a big question about engaging with providers. i think the kind of comments, the doctors do what you pay them to do. this is going to be a change in focusing on delivering the highest quality care while at

the same time providing excellent customer service. that is a different paradigm. i think it is going to be an educational process, a changing of the culture. think about the large hospitals that have multiple product -- private practitioners or inside a university system, where even the university does take into account quality often times in the promotion of an appointment process. it is going to be a big change, and there would be bumps in the road. we changed to reward the bull basin quality outcomes. we have never been charged with doing that. we just want to do as many big volume cases that are cases.

that is going to change. one of the things that i am concerned about is when you use volume as a metric for reimbursement, to have a level playing field to define what the quality parameters you're going to use. one of the things, data came out of new york that was exporting of the difficult cases west of the cleveland clinic. i think that whether by design or just by circumstance, there may be a de facto rationing built into this because we are not going to take on the tough cases and not offer the services. >> we know we need to get from one side of the road to the other. i think everybody is clear that we need to say we are paying for

value. is not aware we need to go that is a problem, it is how we build the economic model. i'm still, as we heard earlier, a lot of my business is still in fee-for-service. how do you think about managing the transition economically? >> i'm going to escape to her think the puck is going to be as wayne gretzky said. we think about the implications of how to decrease readmissions as toby was saying and 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. as we're speaking earlier, there has to be some shift also to

taking away some of the things that physicians have done in moving it down to extenders, whether it be nursed practitioners, nurses, pharmacists are working together as a team. but an incentive that drives behavior. there is a recent paper verifying the surprise that pay for performance actually changes professional behavior. >> one of the things that here is that we have to get out of being in the hospital business and in the care continuing business. to think about the whole patient across all that sides of care. you have been a leader in your private business and in the policy world and thinking about how to rebuild out a more robust continuum of care in different settings and get patient involved. help us think about what that means for hospital.

>> is your party touch on the big changes. people ask me all the time with the biggest change that we are undergoing. metalico the change today. i think the biggest change that we are seeing that can be transformed -- the shift in risk. money flows, winners, losers, also efficiency and waste. risk used to be in the purview of government of the big pay orders out there heard with obamacare big celebration, the risk is shifted to the providers, the hospitals, the doctors. that is what is new. hospitals don't know how to manage risk.

it never had to do it. now it is in the providers. so the hospitals are what we're are talking about for the next couple of days. the consumer is the new element. this consumer is going to be for you stay competitive in this new world. you're going to have to focus on consumer-based experiences that go all the way from scheduling, how easy it is to see a physician or a team come how long it takes, how you were treated. much data is given to in your pda and your personal device, do you get laboratory tests before or after, what is that follow-up to keep you not in the hospital but out of the hospital, which means the hospital is no longer a structure, but like bob says it is an integrated system to keep people out of the hot --

the high cost to a low cost side of care. i'm optimistic about that. i think the government has made think the government has made a disaster over some very good principles in obamacare so far. time to recover, but we will see. i think the leadership has been poor, it has been laid out poorly, it hasn't been done well here it am very optimistic and here's why it is so important what you're all talking about the next several days. technology today, ipads didn't exist three years ago. now you have a hundred million out there and we all depend on them today. 94% of people have telephones and 54% have smart telephones. the associate economic -- that empowerment of data, and data is not electronic health records. information technology is not electronic health records. government pushed a set way. information technology which is

going to drive the innovation which is going to be consumer driven, not driven from above, is going to be automation, decision support to make sure the right decisions are made with the resources that are available by doctors at consumers. it is going to be the connectivity which means an investment to get those tentacles out there to do the outpatient care/inpatient care. the big data means data mining, the sort of stuff we couldn't do before. in some ways to stay competitive you're going to 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 to the connectivity and automation in the decision support in the data mining that is available. if we use is effectively, you can stay competitive and patients can have better outcomes. >> one of the ways that consumers get to help care is through the employer and to the

pay or indirectly. what doctors i can see, what hospitals i can access heard a lot of the benefit structures are determined by employers. that is changing now a lot of the way employers are purchasing healthcare is beginning to change. employers are getting impatient with cost of healthcare in the traditional benefit structures. from your perch, thinking about benefits for employers large and small, where do you think the purchasing behavior drives a hospital business in the healthcare business. how is echoing to change over time given where employers are going? >> employers have always been uncomfortable with the rate of inflation in health care, but they've always manage to pay. are the outcomes of the aca is the excise tax cap that hits in 2018. you can complain as much as you want about the law, but gives you an out as an employer. i've yet to meet an employer is going to pay the 40% excise tax on the system that the already consider efficient.

we have established a ceiling that employers are willing to pay. i think what the senator pointed out is that consumers are going to be exposed to more risk. it is going to come in one form or another. when people start to see how much more they're going to have to pay -- tour only two ways for an employer to stay. the unit you have to raise deductibles or out-of-pocket limits. as a general rule of thumb for every dollar you try to stay under him premiums have to increase maximum exposure to participants by two dollars. if you're talking about $50 is not a big deal, but if you talk about a thousand dollars that's a huge exposure. if you're a hospital that is a huge exposure and uncollectible debt. the second side is if an employer doesn't do it by increasing exposure to participants, they're going to have to focus on much narrower networks. right now the whole network selection criteria has been make sure my doctor is in, make sure

my hospital is in and make sure all the others are in, too. most of the networks around the country are established to include everyone. i think what we're starting to see on the public exchanges and we look expected an employer around is a lot more of these specialized narrower networks. if you try to go to a large employer occupation and sarah will give you access to 50% of the providers in the community, there is an upper. if you go to an uninsured population that is had no covers before and say i'm going to give you coverage a half of the providers in the community, that is a win for everyone. i think as those networks are to get filled, people that are in these bot access net shipment of access problems of their own, you may go to a less efficient provider. so there is a lot going on in the employer community. not just about how we do it smartly because there's a plot of moving dynamics because the uninsured have access to health care. that is good to be a take issue for people. >> this change in high deductible, there are some good things about that. i does bring the consumer in. the consumers we are going to be

bringing in for obamacare to work is going to be a younger population. so deductible five years ago was probably $500. now it is $2500 for most companies. so 30-year-olds are going to be forced today, mandated to get everybody in the insurance pools who will have deductibles of 2500. plus they will be paying a thousand to $1500 and they're going to be the ones going to the pocket, pulling out an app and pushing a button and saying ok. i need an mri. i have -- my physicians as a do and push a button it is going to cost $2200 at the center over here with very well known academic health center in $1200 in green hills and $300 next- door. and the quality is the same on the same machines and this button is telling me that. all of a sudden it's going to

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 is going to have to respond. to me that is going to eliminate waste, inefficiency. 30% of the three chewing dollars being spent today that doesn't go to federal patient outcomes, to me that his rate positive. of course i am more optimistic about the future, but technology will allow and empower the consumer to make those decisions. >> i think it is a really important trend. if you are a high-cost provider, that say a large academic medical center or a big specialty practice, you are probably at the high end of that pricing list on the app. let's just pause -- which is positive the transparent world, the prices are going to a lower level. as revenue that is supporting a lot of other things going on in medical centers. i wonder, from the perspective of the university of miami, how

you think about the economic pressure that this puts unsustainability of these important centers? >> there will be tremendous pressure. particularly when the government is reducing the amount of research money that is coming in. you have no place to cost shift to. the fact is, we're going to have to live in the real world. we are going to bring our costs down at the same time. were going to have to eliminate overhead and do all the things that other providers have to do heard i'm closer to the employer than the provider, so i see it from both sides. i don't think academic health centers will get off the hook. if we are 20% more expensive now, we're going to have to bring it down so that we can compete did i would point out, though, that most people who come into medicare have not have a lot of choice. so they're really coming out of hmos, out of narrower networks.

so moving medicare to narrower network, moving medicare to less choice, may not be as big a jump as some people would suggest. i would, though, say a word about people that can't afford high deductibles. we have used -- we have to be very careful about price sensitivity for poor people, for old people. you're bringing in a lot of young people into obamacare, but we are also bringing in low income workers. with that group we're going to have to be very sensitive about whether they're really going to have real access to health care system if they come in with high deductibles. it will be just as bad as the current system for them. that is what makes it so complicated. the different kinds of patients and people that we are doing with, some of them can live in a world with very high deductibles and others are going to have to be looking forward. or we will end up with lots of charity care for the in

between's. >> i would echo what president shall ayla says. -- of what president shalala says. some of it is made up by the more prestigious places through philanthropy recruiting talented individual to get more grants. you can never make up the overhead by just indirect costs coming back from grants. i am concerned are there has always been this healthy tension between the dean of the school of medicine and ceo of the hospital about fans blowing how you support the academic mission. that is going to be even more difficult as time goes on. i agree that in order to be competitive, the inefficiencies within academic medical centers, particularly hospitals, and a

lot of it has to do with trainees responsibility and ordering too many tests are not the right tests, we're going to have to fix that. there has to be a lot of attention. i think that the really good places will get this figured out and it is artist going to happen. toby showed the graft about the u.s. a consortium people. they're focusing on that now and improving quality and holding costs. that is going to be the ratio we have to watch. >> we took 900 positions out or academic health care center. physically there were administrative positions. we're are doing that corporations are doing. we looked at our staffing and we protected the clinical side, but we took a whole layer of administrative cost, recurring 40 of $50 million in recurring

costs. we had to do that because we can see what is coming down the pike. we're going to have to be a much more efficient organization, both for employers that are sending patients, but we are employers to. we can't afford high cost academic medicine as an institution. >> i think academic health center, as both of your very involved are, for most people in the room, we all need to define our goals. our goal today are patient outcome. we have artie said that, but now for the first time come over the next five years, reimbursement is going to follow outcome of the patient over a continuum of care increasingly with bundling and reimbursement for one year, post transplant. increasingly we are going to move to more macro bundled in person. for most people in the room, the goal for the hospital tomorrow is maximize outcome for existing

resources or maybe less. your role is a little bit different because this maximizing patient outcome that you need to train the cardiac surgeons of the future and the primary care surgeons of the futures and the nurses and the team-based approach -- >> and research. >> and the third column is research. i am academic or had been. you need to justify the $60 billion of research or 20 billion or whatever it is going to be. we need to have a team-based approach. the team-based approach where nurses are elevated, social workers are elevated very the team is responsible for a population more than the individual. if you need to train them.

the time to get on the real world it is too late. we need to put a price tag on that but you need to justify that. for most people the hospital tomorrow is not going to be miami or even cleveland clinic, but maybe less so, it is going to be the other four or 5000 hospitals out there that have to survive. i would again come back to say that survival will be patient outcomes measured heard those were the reimbursement is going to flow. it will be driven primarily by consumer engagement and experiences with 200 million people changing the system instead of just the hospitals. >> so do need 5000 hospitals in that world? >> probably not. if you say we have three trillion dollars, three percent is wasted, but teenage 5200 hospitals author -- but if you have 5200 hospitals out there, in terms of delivery of services, but how you actually go on and get your airline

reservation, is not the way financial services is done today. that is going to be the difference. if you have appropriate allocation of resources where every hospital didn't have to offer all 20 different services, of course you don't need 5200 hospitals. >> i would agree with that. but there was describing, we have seen it in our communities, this arms race of have one hospital gets the latest greatest mri scanner, then the other has to have it. that is going to be over. if you look at the margins of hospitals in the country, a lot

it is going to be difficult to make that transition if you are not part of a bigger system because that's going to be where you get the critical mass. the quality of administrators to make these things happen. >> we have to change the model. we cannot deliver care at the same high cost during have to figure out a way to deliver the care, but hang on. where are all of these deliverers of care going to come from? you don't have enough doctors surely to deliver the primary care. we certainly don't have enough nurses today and inc. about where demand is going. how do we produce enough capacity?

>> let me set up. the numbers out there, 40,000 primary care doctors that use a conventional 40,000 doctors needed today. that is before if obamacare is fully implemented, another 30 million people coming into the system who don't have insurance. when someone comes into the system, their health care system goes up 50% more than when we were into the system. before you factor in coming into the system, what do we do? [laughter] >> stop thinking just doctor and start thinking about how people are trained and allow people to practice up to their training. the fact is nurse tactician or's handle about 70% of the primary care.

we should be using well-trained primary care doctors for the ambiguity. this is the point bill and everyone else has made. we have to create teams. that means physician assistants and pharmacists and other care providers. we have to get over the hierarchy and take on the rules state by necessary because that is what restrains us from creating these teams in many ways. we could handle this primary care if we could deal with the scope of practice issues and if we could overcome our let them to talk about teams as opposed to hierarchy, will we have to train people in the future, yes.

but we have to train them better and use them up to the level of their training and i think they can handle it. most of them have been getting health care in one way or another. health care costs will go initially. that could settle in and these teams of caregivers could organize primary care, chronic care management and life care. there are lots of things we can do to break down the barriers. >> the policy is important. doctors don't like teams. [laughter] you have a patient coming to the door, you are the surgeon, and you have to fix it. listening to a collaborative way to other people, we want to cut, fix and get them done. [laughter]

in all seriousness, this is a huge transformation. our ethics is not to be team- based. we like to say that it is but the practice of medicine today, you are not trained. business school is trained with six people to get an outcome that allows collaboration, integration, leadership and distribution. that's not the way doctors are trained. they're not trained very well to be a team-based approach. it can be done, doctors don't need to be making those decisions but the system has not yet responded. that's going to be after my risk transformation and innovation through patient engagement.

the third is the team-based approach. what we are not there yet. every hospital needs to encourage it. if you have a doctor's lounge, you need to integrate social workers and the epidemiologist and integrate medicine and the yoga specialist and doctors just don't like it. >> economic incentives are driving us in that direction. patient safety and readmission issues, we have been forced to put teams together. i happen to think through team training, we are doing more of the groups together. you can drive it with economic incentives. i don't care people are brought

up, i care about whether there are incentives out there that can drive a change in behavior. >> doctors do what you pay them them to do. the other thing that's going to happen is the game is going to shift from the inpatient side to the outpatient side and to the home. unless we are going to get house calls, we probably won't have time to do it. we have to deploy these other assets and leverage the training of these other individuals. the game is going to take care n the home. in there are programs now to start to begin to train family members as long-term care dividers. when patients go home with

wounds, oftentimes the family member takes care but i think the game is going to shift to the outpatient home trying to prevent readmissions will be a huge thing. >> imagine your non-health care clients listening to this about a big line item and the people who provide that service. we like to work in teams and we have to figure out the systemization thing and how do we standardize and liberate polity product? we have to figure out how we use data. we are making big investments but we've never been a data- driven organization and we want to find more scanners and da vinci robots. how much longer are employers going to stick around for this story versus saying i'd rather not be involved in this anymore? >> large employers are relatively committed to providing the services.

they can actually help them do it better, but they have the excise tax hanging over them. employers are much more inclined today than they were five or 10 years ago to partner with these local communities to figure out what positions and get that out there. overcoming the fence that, it's only done to bring the cost down and really starting to educate the workforce on the fact that some of the things improve the quality of care at the same time we bring in the cost. employees have gotten smart on how to do that and it's going to make a big difference and pave the way in a way you could not have done 10 or 15 years ago. >> 60% of all employers 12 years ago provided health care and now it's down to 50%. that's before obamacare.

people who hate obamacare will say -- i think obamacare sets up the potential for a lot more employers to get out of the business. in the short term, it's going to cost a lot of money. investors can make a lot of money. an employer can stop giving health insurance and gives an that employ a packet of money they can at the exchange, go out of by a good plan. it does not work long-term because health-care inflation goes up two percent faster over time. over time it does and is likely to return and that's where we will get hit. i'm not sure. it's already gone from 60% to 50% with obamacare and now have

more flowing and with a better system to choose from. potentially another 10% to 15% of employers can get out of the business. i want to open that up because it's ok for the first two or three years but after that, because of high deductibles, isn't going to be able to sustain above two percent of gdp over time. i'm a little more concerned. i think consumers will drive the system and i think employers will drive the system because they do partner what you said and the cleveland clinic's are at establishing a culture of wellness and i think employers have a huge role to play. i would encourage them to partner with their community employers. >> if we think about -- if we want to be competitive for good employees, large employers are not going to get out.

the smaller ones cannot spread the risk. they haven't been able to get the prices down, so will obamacare do that in a way which will attract them? i think large and midsize employers will continue to provide health insurance to control costs because we've got to do it. those of us who recruit people from outside their own region, it becomes increasingly important. >> it's going to shift a lot more of the burden and account ability to the patient. you are to have to resume some responsibility for their health care, trying to prevent and keep people healthy.

once we have skin in the game we will probably pay more attention to it. i'm often shocked at how people put into maintaining their car as opposed to maintaining their own health. it becomes a pain for them financially and i think we will see people become more educated and go to the doctor and follow the blood pressure, eat and exercise. >> we are going to have very good data for it. i can even price a car repair because they are bundling payments. they are not cost-shifting to make up for underpayment over here. they will have to become a long way for consumers to be able to compare cost. >> being able to have that

technology will happen very quickly and people will shop, but i think they will shop on a cost ratio but there has been a lot of scholarly work and people will go for cost for the go for quality. >> from your perspective as an entrepreneur, do patients even know what quality is? is it just service quality? >> the overriding thematic has to be improving patient outcomes. for existing resources. how do you maximize the use of resources? it's data, innovative technology, data mining, price transparency. even though it terrible and tough to do, on the first half

of the equation, maximizing patient outcomes -- traditionally we are measuring process measures. we are only getting to the point that true patient outcome through measurement we didn't even think of that until four or five years ago. now the patient is going to demand it. ultimately, the success of the hospital of the future will depend on patients coming in and for patients to come in, it cannot just be a patient engagement. it has to be consumer engagement before they get sick and after they get sick with rent loyalty coming in. >> i know we don't have a lot of time on it, but it gets to the opening remarks.

our outcomes in infant mortality and how long survival is much less. 26 and 30 compared to other countries. terrible and discouraging. therefore, we need what? it is outpatient care am a it is what goes on at the home, it is palliative care. that is why you have to have these integrative systems with tentacles out where you monitor the continuum of care over time. that's where everyone is going that will bring those systems then. outcome is not as good, therefore -- the therefore is critical. if you look at how long somebody lives, it is 30% genetic, 15% how rich you are, socioeconomic