have a lot of very powerful operations thank you have it their way. -- trying to have it their way. >> before i asked the last question, if low wages and compensation were enough, we would be winning right now. other things, other public policies, massive subsidies, things like that which we have not responded well. we have a question which has reached us from the c-span audience. i have been asked to finish up with this question. -- is thearaphrase wto remediable? should we continue our commitment to participate in it and if not, what would replace it? i think those are the questions. question for ag

monday morning. [laughter] cannot prefer an answer that would say it is remedial, but i believe if we could go back to the drawing board and that we could practice in this country or all countries could meet on thequal footing, where all participants in an economy would have input and a say and let their concerns be addressed -- you could create something new on a global scale that could work. i don't say something can't be done, but the way it is right now we have a system that is based really on exclusion, not included in. we know it is not working.

the solution, i would have to think about that for a lot longer period of time. >> it is a very big question and it is bigger than we can answer here. i thought about it and if you go ch.org,website, tradewat there is a global organization called, our world is not for sale. that is unions, consumers, environmental, religious groups around the world. they lay out some principles of what good global trade system would have. i would summarize it very briefly as, you get rid of all the corporate trojan horse stuff that has been stuffed into the trade agreements, the financial deregulation, the promotion of on localng, the limit procurement policies, the limits on food safety. existingct some of the global human rights standards, the rights to medicine, etc. to

become a floor of decency. you make that the floor of decency and you take what is , you puthe trade piece the floor of decency under it that makes it the basis, the national minimum wage come of the national law. you actually have a multilateral trade regime that gets us the benefits of trade without all the baggage, the garbage that has been stuffed into these trade agreements. radewatch.org, you can see more details of that. if anyone in the room wants to buy a copy of the book, it is on the table. >> i think we will have that be the last word. thank you to the economy in crisis association, to all of you and to our panelists.

i think we have the kind of discussion we were looking forward to. thanks. [applause] [captions copyright national cable satellite corp. 2013] [captioning performed by national captioning institute] >> i would like to welcome -- >> more tomorrow with u.s. trade representative kirk they will be part of the discussion focused on the north american free trade agreement which was signed into law in 1993 in an attempt to boost trade between the u.s., canada and mexico. the event is hosted by the center for strategic and international studies.

live on c-span 2 at 9:30 am eastern. the seven move forward today on the budget deal and defense programs built. each passed last week in the house. the senate will return at 3:00 tomorrow eastern time. they will consider nominations for assistant secretary of state and homeland security secretary. votes expected around 5:30. live coverage of the senate on c-span 2. the house has finished its legislative business for the year. they will be in for a pro forma session tomorrow here on c-span. it provided the first country in the world to provide -- this is something that allows monitoring of vital signs without having to have intrusive monitors.

it can be a game changer in terms of tracking people's health and health care. >> we are a remote wireless monitoring solution. to be able to put devices in patients' homes, monitor and keep them well and have better outcomes and keep them out of the hospital. this device does readings. typically a patient that is on -- would have to go to their doctor once a week to get a blood rating. the data goes into this device and it can go to our service center, our nursing center where they help monitor the patient. they can alert the patient's cardiologist. >> one of the things my office is working on is providing a model notice for health apps. for example, when you buy a can of soup, there is that consistent fda label. it lets you look for the things you're interested in. some care about sodium. others care about fat.

we are developing a tool. we have already done this for personal health records but we are expanding it to address other apps and tools. thesean help you say, folks do not resell my information or this is how they use it. thissumer can navigate newly growing and exploding field. >> the government's role in supporting mobile health care technology, monday night on the communicators at 8:00 p.m. eastern on c-span 2. >> i wish you both a very happy christmas and a bright and prosperous new year. it is a pleasure to greet you, mr. santa claus. >> would you mind autographing

some of the christmas seals as a special favor for santa claus? >> why i should be delighted. it is one of the things that i do best. [laughter] good pen you have got, santa claus. >> it is wonderful. my father santa claus gave it to me. and it has got some of the dogs hair in it. >> first ladies, influence and image, season two. this week, edith roosevelt to grace coolidge weeknights at 9:00 on c-span. >> coming up next, a discussion on health care spending and what can be done to remand growing costs. after that, i health energy and commerce subcommittee hearing on online gaming restrictions. later, "q&a" with margaret mcmillan. >> on the next washington

journal, -- >> good afternoon. we will go ahead and get started. i am marilyn serafini with the alliance for health reform. andehalf of jay rockefeller our board of directors, i would like to welcome everybody to today's program. i would like to thank our partners, the commonwealth fund, who have done a lot of work in this area. the growth of health care spending has moderated over the last few years.

experts say this is not the time to declare victory. u.s. spending on health care still exceeds spending in other countries, both in terms of percentage of gdp and also per capita spending. it is also worth noting that medicare consumed 15% of the federal budget in 2012, and in 2011, the first of the baby boomers hit the medicare program. medicare spending is projected to double by 2022. while we talk about differences in this town, today we will talk about areas of consensus, and in particular health care cost consensus. there have been a number of major proposals in the area of health care costs, and there has been work finding common ground.

we are pleased to have commonwealth as our partner today and also pleased to have rachel nuzum as moderator today. she is vice president for federal and state health holiday. rachel will set the stage for us by framing areas of consensus identified by commonwealth on cost containment proposals. rachel? >> thank you so much, marilyn, and thanks to the alliance for health reform. thanks to you who are brave enough to join us on friday the 13th to talk about health care costs. hopefully this is not too painful. as marilyn said, we understand the problem that is facing states and policy makers have done. health care costs are $3 trillion in 2012 in terms of national health expenditures and are expected to rise.

just for some context, roughly 20% of our gdp is spent on health care, and the rate of health care costs goes the way of national health expenditures, but it is still unclear whether that will continue, and what is potentially driving those reductions. regardless, controlling the cost has been a front and center policy issue for policymakers at the federal and state levels where, especially the state levels, and in addition it is families, employers, and individuals. given the policy focus on controlling health care cost growth as well as the belief that 2013 really offered an unprecedented opportunity to arrive at some policy resolution, a number of stakeholder groups released a set of comprehensive proposals to control costs while improving

the value we receive for our health care investment. several of these groups included members and stakeholders, and while different approaches among the proposals, there was an incredible amount of agreement among them. it would be wise not to underestimate the importance of the fact that all of these stakeholders and all these groups were coming forward with proposals at the same time. that alone sends an important message that stakeholders across the political continuum agree that much can be done to control costs and to reform the health care system. it was the hope of the fund to shine a light on areas of commonality, hope to distinguish differences in approaches. there is a piece in your folder that gives you a link to the online tool that was developed out of this partnership. it was the washington university

department of health policy that looked at reports. these are organizations that released overheads of proposals, not just medicare proposals or coverage proposals, a comprehensive proposal focusing on controlling health care costs through health system transformation. after analysis, the examination revealed substantial agreement on areas of action. as i mentioned before, even when the reports differ on specific recommendations, there were enough commonality to suggest momentum in four key areas. you see those here on this slide. paying for value, moving to a system that pays for value over volume, quality improvement in patient engagement, improving market competition, and the setting of spending targets, something that has been

controversial, and i think many of us are pretty surprised to see that in almost all of the proposals. considerable agreements when we looked at that pay for value, not for volume. there are similarities to what is in the bicameral proposals right now as well. that really was part of the goal, to see if some of the consensus could make its way into the policymaking system. just some of the common elements of the proposals. more information in your folder. all of them recommend moving away from current sgr formulas. all of them proposing to build upon or expand alternative delivery models and payment models such as medical homes are accountable care organizations. a lot of agreement on the

importance of using the health insurance marketplaces to encourage insurance practices that supports good purchasing. the quality improvement side, some of the areas that have the most consensus was the idea around the need for core measures and metrics. and alignment between public and private programs and the measures that they use in order to make things more consistent and seamless for providers. again, lots of differences on how the proposals suggest we get to those goals, but much agreement on the need for core measures and there are efforts underway with others to move in that direction. on the improving market competition, i think the area we solve the most strongest areas of consensus were on the ideas of price transparency. we've had a lot of discussion over that in the last year. differences in the way that reports approach it, but and

issue we are hearing on both sides of the aisle, in terms of the importance of shining some light on the cost of care and the prices paid. finally, on spending targets. all of the proposals recommend spending targets, some of the program levels, some at the local levels, and all the proposals emphasize and encourage on the state level innovation. this gives you a quick glance at the online tools that we have available. the online tools link to the individual proposals. we encourage you to look at this to do some comparing and contrasting and then to read war about the individual proposals. with that, i just want to again acknowledge our partners at gw, katie and her team, and thank her for her work on this, and also for the work that katie's team worked with.

they did an extensive amount of analysis with those groups to make sure that we were reflecting those proposals accurately. thanks to all the organizations that participated. marilyn? >> thank you, rachel. let me go through logistical points. you will notice on the screen behind me, if you are interested in tweeting, you can follow the hash tag #costconsensus. you can also use that if you would like to pose a question. send a question via twitter. if you simply use the has tag #costconsensus, we will pick that up. you can also send us a direct message on twitter at @allhealthreform, and we will pick up your message that way. if you are in the room, you can

ask a question when the time comes in one of two ways. we have microphones in the room, or you can also use the green card in your packet to write a question and we will get the question to our speakers. your packet has a lot of great materials for you. it has the full speaker biography. it also has the powerpoint presentations for those speakers who have power points today. we also have additional background material available for you at our website, www.allhealth.org. this briefing is live on c-span today. there will be a video on our website by monday, and that will be followed shortly after that by a transcript. one more point in the packet --

you also have an evaluation for before you leave today. if you would be so good to fill that out, we would be grateful. let's move on to the rest of our program, and we are going to start -- we will hear first from paul ginsburg, who is at the center for studying health system change. paul is a health care economist who is made his business to make sure he knows the trends of health care delivery. we have asked him to discuss areas of consensus, the likelihood of moving forward, given the political atmosphere, and also to look at just how concrete these proposals are in their ability to move us forward. paul? >> thank you, marilyn. as rachel said, there were a lot of activities in developing comprehensive strategies for

cost containment. many of them were motivated by expectations that there would be substantial budget legislation. now, there are opportunities to put these ideas forward. most of these entities are really seeking consensus. some of them had different stakeholders involved. some had conservative and liberal policy experts. some have republicans and democrats. one was from the perspective of states. i want to mention that we served as advisers to the bipartisan policy center. it was released in april. the foundation asked me to synthesize a lot of these reports. they had funded seven of the initiatives. i also added three others. one was a commonwealth fund report. this is really about my synthesis.

the consistency in vision across the reports was really striking. i would use to reports from -- different words from rachel. they are consistent. diminishing the role of service. using other payment approaches to promote care and management and clinical integration. they were seeking improved patient outcomes, as well as cost reduction. the goal is to achieve most of this transition by the end of this decade. pretty aggressive plans. what were the strategies? most of the reports had medicare payment policies as a key lever in pushing the system forward. there was one report that i mentioned called the state health care costs commission. it clearly focused on medicaid policy. that was the key lever.

it is definitely a movement away from traditional policies of cutting payment rates. these reports mentioned the limits of cost shifting. some did identify services where they saw prices were too high. and they called especially for bidding processes to set lower prices. they recognize savings for medicare is achievable only through delivery system improvement that affects all of medical care. the days of squeezing medicare rates and getting a lot of savings, according to these reports, we need to move past that. most of these reports have systemwide policies as well. they include liability reform and the role of nurse practitioners. treatment of health insurance and wellness. the state initiative talks about

state reforms guided by spending targets for each state. none of the reports address quarters of the affordable care act. some proposed change at in the payments and the cadillac tax that are not part of the core. none of them proposed medicare premium supports. principles in these efforts are considered to politically toxic to take on. let me talk about provider payment reforms. many of the reforms do not offer concrete steps to achieve goals for reduced roles to service. many said that we want to have 75% of payments by the end of the decade. how do you get there? those reports are silent. it was unfortunate. for those reports that did specify how to get there, the

levers tended to be provided -- provider payment incentives. some talked about a permanent fix. that includes incentives for physicians to get into integrated coordinated delivery systems. some of the incentives for other providers or more controversial. there were proposals for second- generation aco's in medicare. a lot of concerns were expressed that the current, the initial medicare models had shortcomings , particularly in their absence of beneficiary engagements. they sketched out second- generation aco's and something that would expedite the movement away from fee for service. they talked about a redesign in medicare benefits.

all of them talked about a unified benefits structure. unifying part a and part the, at least from the perspective of the beneficiary. the benefit of the structure includes catastrophic protection copayments. but being politically realistic, these exist with distinct financing for part a and part b alone. they basically asked the actuaries to be creative. attribute spending to the different trust funds. also, a number of reports had particular proposals to discourage overly comprehensive supplemental coverage. they basically preclude coverage from wiping out all of the responsibilities. only the simpson-bowles initiative addressed the

medicare age of eligibility. there were a number of discussions with a focus on revamping the waiver process. it would give greater authorities to state to innovate, using performance incentives on spending and quality to go along with the greater authority. i want to talk about the treatment of health insurance. a lot of people do not think a lot about it and do not realize that the cadillac tax, which began in 2018, is actually now our baseline. the policies for tax treatment of health insurance needed to talk about changes on that baseline. some of the reports focus on a potential shift from the cadillac tax. they would move to the more long-standing approach of having limits on the exclusion of the contributions for health

benefits from employees compensation. some of what we saw on these reports were that this could be designed for greater progressivity. the other advantage is capping the tax benefits rather than premiums. they may have ended certainly done this. let me talk about some opportunities and obstacles for moving forward. another source of opportunity is the consistency of vision. providers, payers, and policymakers. also, the affordable care act coverage, which really starts to hit later in the decade. they are seen as pushing providers forward and making the more interesting in reform of provider payments.

also, i think that the new thinking about federalism has gridlocked medicaid grants for a long time. now, there seems to be thinking on both sides that we can use a shared savings approach. one of the key obstacles is the rudimentary state of innovative payment approaches. this is very early in the game. there are concerns that i mentioned before about second- generation. there is also a lack of readiness and many providers to succeed under reform payment approaches. another obstacle is the importance of consistency in payment approaches by payers. for reforming payments, there has to be some degree of coordination between what medicare and medicaid are doing and what the private payers are doing. there was a fascinating article

in jama from a month ago, about a hospital succeeding. that is subject to incentives. i think that the traditional hostility in the policy world demand side approaches is an obstacle. the demand-side approaches have an important role in augmenting supply-side approaches. finally, the polarization in congress. the absence of resolution on broad issues causes entitlement cuts. that is holding up action on health care cost containment. we are optimistic now with this initiative where they are all working together to fix things. the fact that they are fixing sgr in isolation, as opposed to as a broad reform, as a broad

restructuring, congress will find that it is much harder to do it that way. wait until they get to the -- it will be much harder to look narrowly than as a broad practice. the key thing is holding it up even though there is a lot of agreement and consensus in agreement and consensus in concrete health care steps is getting the big picture deal about entitlements out of the way. thank you. we will turn next to len nichols. he is the leader of the policy on ethics at george mason university. he was to rector of the health policy program at the new america foundation. he is no adviser on health policy at the office of management and budget. he is going to discuss the challenges and barriers to

moving forward. we have also asked him to talk about lessons that policymakers can take from the private sector. >> i would say that the proposals that rachel and paul described do tend to have a vision of where they want to go. where we would all like to go. there are alternative payment models in general. they tend not to have a concrete roadmap of how to get us there. this rough roadmap is being worked out. both in public and private demos and in some places programs as we speak. it is this roadmap or blueprint that we need to construct in ways that work for providers. there are four groups of from -- providers in the u.s. health- care system today. those that are already there, using global caps. they are the remaining

pioneering aco's. those that are trying to make the transition from the service and are mired in the messiness of doing it with conflicting incentives in different reporting requirements -- not all of whom are moving at the same speed. those that are willing to make the transition, but do not have a cooperative payer plan partner where they are. they are frustrated and they are worried and they're moving too fast. and too slow. they are worried about being left behind. they are worried about getting ahead of the payments, so they are sacrificing revenue without having new payment to make up the difference. finally, there are those that are opposed and will fight to hang on until they retire.

in my view, our job is help the good guys. frankly, it is not clear to me the new policy is required now. there may be more nimble authority and maybe a manhattan project. i am serious about this. if i was in charge, which there is no danger of happening, i would assemble a team of advisers to work out a map to give away as a public good. if you think about the medicare fee schedule, it is essentially a public good for every plan in this country. they all use it. we need a new way of paying. why not devote resources to that roadmap for us all? i love the fact that so many -- proposals mentioned the states.

there are state employees that have a big chunk of buying power. in some states, all payer claims databases and some nimble antitrusts could be key tools. medicare must lead. it is the biggest buyer. it can only lead if the private sector will go where medicare wants to take it. there is a public and private ownership. shared savings with states are simpler. they are good ideas. it is heartening to see so much support for that across the spectrum. in any event, rewarding states for simple metrics, like improving quality performance, is a good idea. the sgr fix, as paul said, is a good idea and the challenge. when you see everyone in town agree, it is stupid to continue this policy.

yet paying for it would have been a lot easier if we had been able to lace it in a bigger deal. some want a condition to fix on a payment model. that will ultimately make fee for service was attractive overtired. if you think about it for five more seconds, that is not much different from what we're doing now. the trick is not the formula, but the willingness of congress to enforce the attractiveness over time. to make the transition to these alternative payment models, we must know what and how we want to pay the good guys. think hard about who are the good guys. are they the people who just adopt the alternative payment model and do not control cost or are they people who control cost even with the service? i point out that the vast majority of our patients are using this

service. and shared savings as key complements the payment. bundling, as much as i like it it cannot be done on much is spent at the moment. nor is it likely to be done anytime soon. the point is, it will be with us for while. that is why we have to get the code relative to procedure codes right. we all know which stretch and -- which direction that needs to move. i ask you this question. is the medical profession ready to do this? really, i would say that policy, if anything, has deferred too long to the ama dominated committee. we should blow that up and give this to the other group.

giving medicare enrollees financial incentives is a good idea, they use networks should have been part of the original rollout. it is coming. that is financial incentives for a tighter network. look at these exchange products and how many are limited. it is definitely a portent of things to come. so many proposals mentioned doing something about medsup. it is interesting to me that all of those proposals restrict the kind of policies that can be sold. rather than taxing the product. as an economist, i will tell you that you can structure taxes to drive people where you want them to go. without denying the right mutually desirable products. that is, by definition, being sold today. denying the right to sell my

opinion is risky. in today's climate of hypersensitivity to freedom being taken away. the absence of the premium support and proposal is not shocking. it is too bad. that is clearly on the table and congress. the debate it represents is a the debate it represents is a major strategic choice between relying on health plans to enforce spending limits. the government separators are key. or depending on providers to respond to public and private payment reforms. in other words, do you want health plans to run our system or do you want providers? in my opinion, our country is large and diverse. each will lead in different parts of it. the question is, who will set and enforce the discipline of the target global cap rates over time? it seems to me that no matter what, we need government and

private payers to incentivize providers to hit socially desirable growth rates with hybrid payment mechanisms. i have always been confused by those who hate ipab and love medicare vouchers. take a deep breath and step back. they are after the same thing. holding health spending per capita to something close to gdp growth per capita. there is a dispute over the growth of level of benefits. there is a difference in who bears the risk of failure. there are beneficiaries -- but there is way more in common than the antagonists have admitted. our debates would be more honest and more productive if we analysts could help them to see the essential similarities in the indications of their proposals. the cadillac tax simply taxes the exclusion. there are examples of where they

were in favor of nonstarters before anyone had heard of the security act, much less the aca. i agree with paul. i spoke with self-insured firms last june. their ceo clients already directed them. make sure that we do not pay the cadillac tax. six years before they come into being. that is a hugely impactful provision. overall spending targets are possible only when the math is clear and performance can be fairly judged against objective standards. risk the same things we have seen in the sgr. it seems to me that the biggest political barrier is sustaining the lower cost growth. what will the savings be spent on? deficit reduction or coverage expansion? the aca answers the question in one way.

maybe the fight was harder than it needed to be because the aca was not coupled with a long-run fiscal balance agreement. maybe a long-run fiscal balance agreement was resolved on its own, because we did not yet have an aca. now we do have an aca. it seems to me that the aca supporters ought to give firmly behind some credible version of a long-term fiscal balance agreement. maybe this little, but important agreement that congressman ryan and senator murray have worked out is the first step toward that. the final point i would make is that i was very intrigued by how many proposals talked about sin taxes. what are these taxes? maybe this would relieve the split. conservatives hate sin but they

hate taxes. it is confusing. it has always been a good reason to do this. the social economic status of smokers says it is a tax on the lower income. unless you give them access to effective ways to end addiction. it is that kind of trade-off. thank you very much. >> thank you, len. before we turn to our last figure, i want to remind all of our viewers that you can submit questions that we will pose to our speakers through twitter. you can do that by sending us a direct message on twitter. also, if you are in the audience, you can use the microphone. if you want to get your questions ready now, you're welcome to write them on the green cards and our staff will pick them up. let's turn now to the faculty of the harvard kennedy school of government.

sheila has a long list of credentials that you can find in your packet. she spent most of her time in washington working as chief for bob dole. she also worked on the staff of the senate finance committee and spent time as secretary of the senate. she is going to talk to us about the accessibility of the major components of various proposals. sheila? >> thank you. really, my congratulations to the commonwealth and the others, who did a spectacular job of bringing folks together. paul essentially did an array of what it is that was out there in terms of proposals. he gave us an opportunity and a way to find where there are areas of consensus. there is an opportunity for us to build upon the work that was done in the past. kudos to commonwealth and others

who participated in that process. as marilyn suggested, i am being asked to give you a sense of what i think the political realities are of what has been put before us. i would also note that the cbo has recently put out their ongoing health-related options for deficit reductions. that is always an opportunity to look at how cbo looks at these issues and think about the savings that would be accrued. there is certainly a host of proposals out there. i would like to step back, if i can, and reflect on in part that rachel mentioned and what paul has described as the building block for what i think we might see going forward. there might well be an opportunity for consensus. i have to say, having been a staff member of the senate finance committee for a long period of time, and on the senate staff, i have to think of what occurred yesterday.

it occurred in a very positive way, not as a negative that they failed to do the paid -- i think what it showed, and what was mentioned by senator dole, who commented that it was nice to see bipartisanship coming back. what we saw in the finance committee, what we saw on the ways and means committee is the beginning of a conversation that began a number of years ago. we're coming back to it. that is refocusing on the programs. we're refocusing on the elements, which both sides of the aisle have the opportunity to look at and discuss. we have already found a number of common grounds. i think this will carry over into next year. what occurred in the ways and means committee is the beginning of that conversation. it will take us into the new year. we will be able to look in greater detail at what occurred

in turn to what has not been identified. the absence of that at this early work does suggest that there is a willingness to take on some of the hard challenges. i think that there is a very positive movement forward in looking at this program and the changes that could be made. i think that rachel, and some of her summary, and much of the work that paul did, did identify common themes. they are themes that are broader than simply just the payment changes and the provider cuts which we have seen so recently. heard in the discussions that occurred yesterday, issues around value, value versus volume. the sgr is a piece of that but it is really a broader conversation about what we do with payment incentives and payment programs. a clear focus on quality. a clear focus on metrics and performance.

again, something that has been coming for some period of time. some are more ready than others to engage in that. i think shared decision-making is part of that. figuring out how to incentivize both physicians as well as the individual consumers and systems to participate in those programs , putting clinicians in charge. there has been a long-term sense that much of what is occurring is up to the taxpayers. we drove it as public payers or private payers. there's a clear interest in figuring out how to incentivize physicians to become more actively engaged in the broader management of what is occurring in the systems. not simply in the silos that we have seen in the past. i think that timing is always an issue.

one might imagine the changes that we have seen in the aca that play out over a long period of time. really, the readiness that was pointed out is very variable. the opportunity to analyze data and use it to drive change in behavior to try to drive a certain kind of behavior on the part of the clinician. the access to that information. how it is utilized and by whom. that clearly is an issue that varies across the country in terms of how organized systems are. some are more readily able to access that information. they utilize it in organizing their systems. there are those who are trying to make that transition. they want to access that kind of information. but it varies. certainly, bundling.

it is limited to a limited number of circumstances. the concepts behind that is really about how we break out of the silos and begin to look at the full continuum of care. the opportunity to look at what happens pre-admission, during an admission, and post-admission. i think that traditionally, the payment systems have encouraged those silos to exist. silos to exist. now, through bundling and other efforts, what we're looking at is an interest in looking across the entire system. that obviously creates some real challenges. some of those relationships do not historically exist. whether in the postacute environment in nursing homes or other facilities, and home and community-based care -- but there is now a growing desire and need to understand how to help that patient manage. how do we create a payment system to do so? certainly, the movement, whether through acos or other organized systems of care, the problem is

that there is not a single answer. we heard in yesterday's discussion that some of the unique problems that exist in rural communities -- you essentially do not have the number of providers available. as we look at what has been ingested in the proposals before at, we have to look provider differences and has to be recognizing it it will not be one solution. there is an importance in the federal and state bishop, bipartisan,at is and that is the understanding of the value of the role of the state, how the state can incentivize behaviors. the state can have authority, orther in insurance regulatory environments. the adequacy of networks is something we need to look at,

certainly with respect to workforce. the demand on primary care, the increasing number of people coming into the system will put pressure on it, so as we look at incentives to create more opportunities or more providers in those environments, near and dear to my heart is there a role of nurse tactician errs and whether they can practice to the nursextent of their -- practitioners and whether they can practice to the full extent of their education. also team-based care. how do we incentivize those kinds of things. there were a lot of allowance proposals we looked at and in the work that takes place that provide an opportunity to move forward, but there are take differences, and it would be foolish to ignore them. the budget and the concern about the deficit -- how we focus that on the health care programs, knowing they will be caught up in a broad conversation about taxes and the entitlement programs. the lack of readiness on the

provider level. the, clearly wide, and i think both parties will approach that differently, depending on what they are hearing from constituencies. the opposition to demand side proposals, as paul noted. no question, resistance to increased exposure for beneficiaries, but on the other side concern about how you get skin in the game, how you begin to have people pay more close attention. the issue around medigap coverage is one of the issues, how do you encourage to discourage the purchase that covers the first dollar, do you otherwise try to incentivize their behavior in terms of decisions and choices. the politics of these discussions inextricably inked to the tax discussion. in the did not see finance committee, we did not know anything about tax extenders, which will come out in the course of next year plus discussion on a broader tax debate which made back the

broader entitlement debate. varying demands from payers and payer systems. the lack of consistency among payers and the way that providers have to respond. essentially require certain kinds of behaviors or do you leave the open market system as has been suggested? how do we incentivize the states? one of the issues we have confronted in the medicaid, medicare discussions is how do you encourage states in the concepts of who is a little when the savings accrue at the federal government cause of the acute-care sign the program? how do you get states flexibility and ownership of those decisions, but essentially achieve a broader set of goals? the roadmap, as suggested, i think len is correct, there are those who are ready who have the are trying,ose that those that are willing to try, and then there are those who are

, hell, no, not until i retire. the politics of the provider community, internal to the house and the senate and the discussions around the aca which have come located that will make some of these issues difficult, but i believe i have to say a glass half full because what happened yesterday gives us the basis on which we can move forward and refocus on the programs and their future. i would say closing, the other thing we have not touched on to date, but i think we must touch on is the federal government is a purchaser in a variety of ways. medicare, and kate are not the only ways. whether the tri-care program, all the other systems, we have to move forward in a comprehensive and consistent way in terms of the way we organize finance and incentivize the haters on the parts of all our systems, and those systems which have their own politics have to be brought to the table as well. >> great, thank you, sheila.

while folks are getting their questions ready, i will ask the first question. this has to do with the concrete nature of some of the proposals that are on the table right now. panel asike to ask the specifically about spending caps and targets. the way the proposals are set up, would they really come into play? sense of the proposals is unlike an sgr, where the spending caps drives things, the approach that these proposals took the spending caps that they were a act up, and they were therefore cbo. what is different is they were laying out concrete policies, which, if they work out, should keep spending below the cap, and the cap is a act up. even as a backup, the notion would eat that if it is

triggered, the response is not a mechanical reduction in payment rates, but a ramping up of some of the policies that were designed to lower spending. >> i think paul is exactly right. i think experience with the sgr has caused people to be concerned about the role of cats, however they are constructed, how mechanical they are. we have seen in fact since the continuedof the sgr, pushback would occur. in designing any kind of a program like that, the question is how credible is it, what is the result of it, and in fact, it is a act up or mechanism that automatically comes into play, and how that decision is made? people has resulted in being cautious about how those are constructed. >> let's start here. please identify yourself. >> hi. the differentsed,

proposals that have been presented today. i am interested in comments on which ones are most elliptically feasible and also would give us the biggest bang for the buck, if people could comment on two or three that you think would meet that kind of criteria. i will take a first stab at that. i think -- and i would like to hear the comments from the other panelists, from the commonwealth fund's perspective, our take of looking at all these comprehensive proposals was to identify the areas where there was the most agreement and more common focus and similarities in approaches. i look at those as possible areas for a path forward.

havethink, you know, we talked about many of those areas that we think and to be pretty promising. the movement from a way from paying for falling to paying for value, this widespread agreement, has the need for more consolidated and aligned quality measures. i think the directional movement on price transparency from all those -- many of the areas change. that was really the goal of. the project is to identify the main areas of consensus so we could go a little bit deeper and that groups could work a little bit more closer to the ground. but other folks might want to talk specifically about individual proposals. not as a sympathizer of reports, but as an analyst of health care, i believe proprietor payment reform has some of the greatest potential to really move the dial.

i think that is worthy of a lot of energy on the part of the congress. is thathe key things you have to have a link between andficiaries or enrollees the organizations such as the o. that is trying to deliver more efficient care. without this link, that limits it. were part of the bipartisan policy center, and the formmended enrollment model beneficiaries, where they get incentives to enroll, and we did not call them aco's, we call the medicare networks, which i think paved the way for more success, prods,o used the the incentives of favoring the providers in that network. >> i would add that i would say

none of them are going to pass as they are written. nothing ever does. what i would look to and is precisely the point of the exercise, look through what is common across them and there you see the things with traction. i would totally agree that payment reform or basic incentive realignment with market-based tools like transparency and quality measurement and so forth, that has the most legs and i think the most potential for a bipartisan agreement going forward. >> i would agree with all my colleagues. i would add one element, and that is the question of workforce. i think there is not that growing understanding of the need for team-based care and a more collaborative environment rather than it being driven by in this case decisions, in most cases. but an investment in primary care, an investment in a

essentially incentives that create these teams so that essentially when we approach a patient we look at them across a broad array of services. we increase access to services. i also think the emphasis on moving people out of an acute care setting into a home-based or community-based setting, the investments in essentially developing those assets and people that can care for folks in those environments and making it again to a payment system that rewards essentially that kind of coordination. i think there is a fundamental agreement and understanding of that, and how that plays out state-by-state will be somewhat different, but i think there is commitment isng certainly do those things and that will change. >> if i could say one more thing price-- ritual brought up transparency. the point i want to make is -- ortransparency can be transparency in general, really, can be a very useful tool as an adjunct to something else. it is really as an adjunct to

different types of benefit designs where there are are incentives concerning which provider you choose. be an adjunct to the front network type approaches. if you want the beneficiary of nrolle, to get a sense of what network they feel most comfortable in. transparency on its own as a risk of snakes in its wheels, disappointing people unless is hitched up to the perhaps harder policy to pursue where it plays a supportive role. why don't we move over here, and if you could please give your name and affiliation, please. >> i'm a primary care physician. rathera brief comment than a question. you have presented here what the consensus is among a wide swath of the policy community, but it is not among everyone.

the focus in these proposals is utilization, that the beneficiaries need to have to mature skin in the game. commonwealth just produced a report saying americans have more skin in the game than anybody else in any other developed country. there is also great concern in the physician community, the american of the american college of physicians, for example, does not represent its leadership but not necessarily represent its membership. whoe are health economists think the problem is not utilization, but the problem is prices him and it is not physician prices, it is at least under medicare it is prices of images, drugs, tests, the three we haveaccelerators

in washington. none of these proposals do anything about that. by the time your proposals again, the accelerators are here and who is going to pay for them? that will be loved into what ever fees are charged, bundled, or otherwise. bundled intobe whatever fees are charged or otherwise. >> that is an important point that we looked at a specified set of comprehensive proposals that certainly do not represent the totality of all of the ideas out there right now. i do want to clarify, though, and say i do not think that the proposals were limited to looking at limiting utilization, and i think in fact, that is a criteria for selection of the proposals that we looked at. we did not talk about all the provisions, but i think another key element that was in many of the proposals was a focus on beneficiary engagement. that is different than having

gettingthe game, beneficiaries really engaged and giving them more choice. in fact, there is a significant agreement among even some pretty abstantial proposals in to different medicare-type benefit package. i want to clarify it is not just all about limiting utilization among the proposals that we selected. ok, the other side. >> hi, national coalition on think thee and i commonwealth fund and the alliance for doing this. i wanted to return to a point that i think both paul and len made and sheila different a little bit about the notion wouldn't it be great if the sgr reform was part of a broader agreement, closer to a grand bargain, brought entitlement reform -- brought entitlement reform?

i wanted to attack that a little bit. would it be possible, given where we are at now, we come to march, and for lack of that if folks kind of back away from attempting to do sgr now and pay for it in smart ways, wouldn't we undermine that kind of confidence-building effect that that would have? i would like to tease that point out a little bit, from the folks. you do not want to have misunderstand. i mean, it would have been great had a grand bargain been available and if agreement had been reached on a whole variety of things rather than a relatively limited package that has moved to the house and is about to move through the senate and a separate sort of sgr conversations that will continue into next year.

no question, a great many of us on both sides of the aisle had hoped that we would have a much larger conversation, certainly reflected in simpson-bowles, perfected in the work that paul and i were involved in at the bpc and other places, the presumption that the best scenario is the one that looks at this in a much broader context. my reaction was simply that -- i guess too many years on the senate staff said that incremental is not always a bad thing. sometimes the opportunity to begin the conversation and make itself to as lends broader conversation. i think what it did was allowed people to come back together and work together in a bipartisan not seen that. i do not recall the last time the finance committee at a markup, but it has been quite some time. in talking to some of the staff and saying onto looking forward to it and a say i have never been to remarkable for, it was

an interesting six prints. three or four years. if it does nothing more than get people get back to the table, get the sass working together, what i understood was a collaboration, both on the senate and the house sides, i think there is an opportunity there. yes, would it have been great to get a grand bargain? want toly, but i do not suggest that what was done was not in fact important and in fact lends itself to a broader conversation. >> if i could say one thing. what i was referring to is really doing and sgr fix on its own, it seems the pay force have ors have tothe pay-f come for medicare. whereas if you do it more a fix., there is fors are easier if you

have a context. i would second the point that learning to do bipartisan, even at a birthday party, is a really good idea. will turn to this question here, and then we will go to a question that came in on twitter. i want to remind our c-span viewers that they can submit questions to us via twitter at ostconsensus or a twitter healthreform. >> one of the things we have talked about is a shift of paying from autumn to quality and value. one of the levers is quality measurement. i am a big fan of this. it is admittedly a science in its infancy, and some of the implementation has been a little

less than ideal, and there has been a big pushback from from positions in prayer the writers. i'm concerned, are we creating a generation of physicians who are alienated from these sorts of repurchase the quality measurements and performance? >> i can answer part of that question. what i have seen over the last couple of years is a tension between measuring quality or value at the level of a provider organization versus the level of an individual clinician. i heard a lot of these approaches are in never going to work. at the level of individual clinician. i am concerned with the attempt to try to do that. for me, i think the focus should be to encourage the development of organizations that can take on these responsibilities because we are never going to be able to build a direct incentives into the medicare program for individual clinicians that makes sense to them.

>> i would just add that i agree with the individual physician versus group point that paul made, but i would add that there is a difference between ensuring quality for a clinician to continuously improve their organization's performance in measuring quality for the purpose of computing value as we are talking about in these contexts. the dream, of course, is for you all to inform the idiots making the payment am right, and that is why you had a process. i think what all our proposals call for i think, at least one that mentioned it, was more standardization, alignment, i believe is a nice phrase rachel used, but a standardization of the quality metrics being required. i know an integrated system in virginia that is producing something like 249 quality measures or different -- i do not know what the right number is. it is not to 49. i think you got to have this

process, but you got to start. we cannot feed paralyzed by the absence of perfection, and you know this, and so we will go from there. >> one final addition. the other thing that has changed is that more people now talking about not just the measure of quality, yes or no, but having a more informed conversation about how is the data going to be used, and it is very different to get providers on board, and there are some things that people are comfortable using, quality out forms to make palin decisions, and there are some things you know as you make care decisions with the patient. so i think there is a more sophisticated conversation going on right now about quality measurements, aligning those, but also before you are just collecting measures to collect measures, what are they going to be used for from and this understanding that not everything needs to be tied >> >> to benefit decision-making. i want to underscore the point and i agree with

richer. there is a more collocated question today and a more nuanced one. in all the proposals commensurately the work that we did at bpc, there is a sensitivity to the indicators that people breathe asked to track. the cost and the word in on individual providers as well as on the systems, the desire to essentially simplify the process am a make it rich, but make it appropriate and morse and the guy said we can't agree on the uniformity or at least some kind of consistency that providers systemsrunning multiple and the burden of that. there is absolutely. nqf isho is now running invested in understanding cap and developing criteria can be best allies. there is a conversation taking place that touches on a very important issue you have raised. >> ok, from twitter --

one provider payment reform that could be instituted that would demonstrate a shift away from the for service? i would ask the panel to give us a sense of the level of consensus on this one provider reform, payment reform. , i can't -- one thing i want to bring up is in the bpc report, there is a simple thing that providers that are part of and the medicare network or have episode bundling contracts yet higher payment rates. a big difference. >> that was great. >> that was i was going to say as well. there are commonalities among the proposals about -- we've been talking about the sgr's. exempting providers from a

threshold per my -- threshold amount, 25%, of their asian practice, and these new provider arraignments, primary medical homes, exempting them from the sgr freezes or scheduled physician payment rates that happened under sgr repeal. that is one element that sticks out. all the proposals address that in some way. they did not all agree on the level or for how many years, but they addressed how you deal with medicare providers. >> i think it is interesting that both of my very learned colleagues immediately talked about increasing fee for service for the good guys. it shows you how hard this is to move the ball really fall really fast. i will go out little farther on the limb and say some kind -- i do not know exactly what kind -- but some kind of pmpm to

providers who are willing to demonstrate they can do coordination for all the good offf, and there is a start that in a kind of a cumbersome way in the enc on a bipartisan basis, and the senate has a version where they can play pmpm 's for being certified. thaton the board of organization, but i think the idea of rewarding our merry care entities for taking on responsibility -- what i would like to do is link that to some kind of risk down the road, some kind of performance base. maybe the thing grows over time if you bear morris. the key thing is eating the clinicians to be aware of the total cost of care. that is really hard to do,

believe it or not, in the current system for most american are. airs. what most pmph's is show that docs the data, and docs are usually shocked. i did not know that. hitting the data in the doc's ha ays, getting the pathw to the solution and rewarding them for the infrastructure they're going to have to build, that seems something worth voting. i will say the evidence on pcm ih is not thrilling. costd evidence pretty -- evidence pretty mixed right. we have not designed the perfect a bee. that is what i would say medicare could do with a little more oomph. >> thank you. we have a question. a couple questions, actually, addressed to paul, if you would not mind kicking us off on this, and then sheila and len, if you

could respond. this is a much broader cover station than -- cover station then we have time to get into today. what do you think is going on with this health care spending growth slowdown? is it real, is it going to continue, and how much of it can we attribute to potentially systematic changes coming out of butbly not thea aca, the systematic changes at that level? >> that was a very tough question. for everything i have read and from panels i have into, i have been to, clearly the recession and its aftermath was a very large factor in this, and hopefully that will go away over time.

i say hopefully because hopefully the economy will come back. there doesn't to be some evidence of some structural changes -- there does seem to be evidence of some structural changes that need to be made. not the aco's. what people look that when looking at aco's, they are not saving a ton of money. there is evidence about how technological change has slowed down, and as it has slowed down because it is running and has things to do, or because of the recession, because the market is not there? i think some things we are going economy isonce the restored, is we are still going to have a much more payment of the point of service by paid patients, we will have incentives to use provider some more than others, there is a lot that is going to be

continuing in a stronger economy, and i think that will have an effect. ofi am optimistic that some the slowdown in spending will be -- butned and probably probably will not be as extreme as it has been in recent years. >> i think it is fascinating to observe that the slowdown actually began a couple of years in 2007, for the recession really hit. contributedecession to it, no question, but it already started. so what is the deal here, and what has continued? we're speculating here, so i would just say in my opinion it has to do with the fact that a critical mass of health care decision-makers had figured out we got to do something about our health care system's costs. i start with employers sending

the signal, sending the signal that we got to find cheaper ways to do this. hospital leaders -- i have never seen hospital leaders unanimous in being aligned around this point. we got to reduce cost. before the aca. what the aca did was kick in and turbocharge it and really down a marker. we are not going back. let me tell you a secret ash real.pdate reduction is it takes learning out of hospitals forever, basically, at an increasing rate over time. that ain't changing. the penalty on readmissions, which gets worse over time, these things have focused the minds like never before. there has been a system-wide ok, they are serious this time, and some of that is going on. i think everything paul said is right. i think the technology think maybe as important in the short run as anything else. >> i think it is both, a, nation of all things that have then touched on.

there will be elements, that will be sustained. we are also looking in terms of the aggregate at this bubble of baby boomers that are coming to the system that will certainly put enormous pressure on the system. many of the elements that were contained in early work in the sensitivity -- and the sensitivity on the part of players of employers and others about that is not going to go away come and many of those kinds of changes will be sustained. >> the good of this microphone. ok, let's go to this crime. ma media. what we know about increased costs for emergency care, also for delayed treatment of known and medical concerns and conditions? can we make comparisons with the solar health care costs and other nations? ownnt to mention in my personal medical experts this year, i got a referral in august from my general practitioner.

i was not able to get an appointment with a specialist until the end of november. then when i needed to be treated in september, they told me to go to the emergency room. that had to be more expensive, i think. i made to a more jazzy room visits in september as -- i made two emergency room visits is ever as a result of that. >> i do not know if we know anything more in terms of what you're asking than we have known for quite a long time. ishink what is fascinating part of your store is when you look at -- and maybe i am --if you look at what physician groups have to do to qualify for the private- cmh's, whichned p are by far the largest number, the first thing they have to do is figure out a way to give 24/seven access, and it could be that they have to have a nurse on call and call them whatever, but they have to find a way to address the question of a human

theg who needs care outside nine to five situation. that is a precondition for been the payment bump up whatever you get to join the program. weis unambiguously true that have learnt because payers are 7illing to pay for it that 24/ access has a cost-reducing effect. it also has a beneficiary having this effect because you're not just off if you do not have to wait and all that stuff. those things are holding consumers in their. we know going to the er, when need, isot k ridiculous. all that has been known for quite some time. i do not think anything new is there to learn. >> you asked about international comparisons. we know we are paying more than any other industrialized country for health care in total and per have, and americans are more

likely to go to the emergency room room because they do not have access to the usual source of care that anywhere else in the country. have good emergency room metrics. >> one thing that i thought that might be a factor is the distortion in our fee schedule. the fact that we pay so much. more generously for procedures than four visits. that may have something to do with you having to wait months for a visit with a specialist. will take exception to that as a specialist, if i may. >> go ahead. >> i do not want respond to that question, but i will. three or four months is ridiculous, i will agree with him, but i do not think the difference in pay has anything to do because specialists are overrun just like anybody else trying to do clicks. there is much a shortage of specialists as our primary care. one of the other things before we jump on the primary care

bandwagon, look at the training of the primary care docs now compared to them 20 years ago. len as an antidote, and knows this, before i left washington i looked at who was coming into our clinic, and over a five-year. period, we had a 300% growth in patients with functional disease that should have been cared for by the primary care. why did we have to see that 200% increase which ends up delaying the patient with real disease coming in? before we get into this, remember we have to get down and look at a few other things, and i will segue into my question -- a few other things is training. you got to look at training, of how they are being trained. second, it took us an hour and a half into this program before rachel tensioned data that len mentioned four more times, paul

alluded to transparency, but without the data, why do we do it? comment about doing a manhattan project is great. being tovided in this, get schizophrenic -- being too schizophrenic. equality aceson of what i did in 2013 and paid in 2015 is like what we are taught not to tell the mothers, say, johnny, you are bad, wait till dad gets home to spank you. you got to put it into the context of when you are doing it. how are we going to have a manhattan project? infrastructuree to get timely data to the physicians so they can make the improvement?

i will tell you right now a lot of the associations that are doing the quality measures are starting to say, what is in it? where is our association? are stepping back from that. they do not make money for four or five years. i ring that up that l -- i bring whenup that len said that physicians see the data, they will change. when you get physicians comparing what they do against their peers, locally, regionally, nationally, giving them tools to change, whether you do for any payment model or incentives. own wanted to add from my experience of a specialist told me later when i saw them a few weeks ago that if i was already in the system, they probably would have seen me. that was like a first-time referral. that was the reason they told me

to go to the emergency room. that is what they explained to me. >> this is not meant as a political comment, but the likelihood of cms getting a lot of money anytime soon is unlikely. but i think there is a great deal of sensitivity to the timeliness of data. one of the issues that paul and i contend with in the work we age doing with bpc is the of the data. this has been a longtime problem with respect to medicare. len is exactly right that one of the credibility issues with respect to the indicators in quality has in fact been the time lag between essentially the acquisition of the data and the analysis of the data and the practice. there's no question that we have to find a way to make things more relevant, more current month and a more credible as a result, so that people can essentially believe that what they have been given is the basis on which they can make change.

in the near-term i do not see a commitment for a manhattan project, the but the point is a good one. >> so i got to say, there are many things i do not understand in life, and i would start with the american league and the chinese language, and how come it is that the private plans can g, andu data with a 1/4 la let me be clear, the private plans to the processing for medicare, but somehow or medicare cannot do it in two years. i do not understand that. we do not need more money, sheila. you need different people. i cannot figure this out. speak,ou're going to join us at the microphone. understanding in medicare you have a year to split the bill and they wait until all the bills are in. >> the insurers have the same lag. are doing on a rolling

average for medicare, which waits for averages. >> it turns out all i know what docs,te plans are giving and somehow it is enough to get a good guess here. it seems silly to me. >> ok. >> i'm with the commonwealth. a couple of authorizations -- observations. one is on the distinction between the discussion of skin in the game and the distinction between rewards and punishment. i think one of the encouraging things that i see across all of these proposals that we have been talking about today is there is an emphasis on changing the payment system so you reward good behavior, and we need to think about the health care system like that. it is not about punishing bad behavior. good behavior.

right now we reward bad behavior. it has be a change -- that has to be a change. we think about the trend in health care costs. i remind -- i am reminded about whether people are saying health care costs are slowing or what is causing the slowdown is i get the sense it is a spectator sport, and health spending is not a spectator sport. it is something that is generated by millions of decisions every day and is an ongoing thing. whether or not health care spending has slowed because of a recession or because there were structural changes, we need to make sure whatever happens in the future sustained a level of health spending that we find sustainable, and that means action and not just sitting back and watching and waiting. and i think there is action on that front. they're both public and private initiatives that been shown to

be promising. one of the private ones that we have done a lot of work on is the alternative all of the concert in massachusetts, which boost cross blue shield in massachusetts has done, and what they have done is one of the incursion things they have done is taken data and shared with her fighters to compare -- with providers to compare their behavior not only with other providers in the state, but also perhaps fighters in their own practice -- but also providers in their own practice. blue cross blue shield will tell us how she goes into a doctor and point out that the bought dr. next door was prescribing a different much more expensive drug for the same condition that a doctor that she was talking to. and the doctor she was talking to just did not know. i think getting that kind of transparency, and i agree with paul that transparency that is hitched to some workable legislation rule situation has to be done.

and the last point i will make is one of the things that drives me crazy about people talking about health for form is this notion there is a shrinking pie. people talk about blood running in the streets because providers are fretting about the shrieking i. if you talk about over the next 10 years, there are on the order of 50% or 60% more health spending 10 years from now than there is now. i would posit only in health care would that be called a shrinking pie. [laughter] great. i would go to one on the cards, and then we will come to you for your question. we will shift gears a little bit. len, you have a question about what you believed the role of antitrust should be, back to health care reform efforts, and what you may have meant when you said the need for more nimble antitrust? >> good point.

i would hope that somebody would take that bait. it is mired in the past in that it really is focused on structure and predictions of performance. and basically, i would say there has been a tremendous emphasis on organizations proving clinical integration efficiencies before a merger is approved, but they tend to lose in court. they have gotten frustrated over the years. my point would totally be this -- sometimes antitrust needs to be more in my view accepting of the newosition that indeed vertical integration and new virtual integration agreements may be more worthy of getting a pass than they have in the past,

but also we need to be aware -- i mean by more nimble am a sometimes the antitrust remedy is just too cumbersome for current law. there is very little you can do about local market power if there is one hospital or no matter what you wish already one group of cardiologists orthopedists, whatever, pediatricians, so they can hold everybody hostage. if you're in that situation, antitrust is a very cumbersome tool. you to think about this i hate to say it, but i will -- you need to think about regulation in that context. i think of regulation as the as i-case last door, but am an economist, but in the absence of anything else, what do you do? what you could do, and this is what i mean by allowing more nimble permissions, i think domestic medical tourism is greatly underused. i know a retired surgeon in the

months into six retirement, got more out of his mind like most of us will, called up a mining owner he knew, and he said, let me help you? he looked at his data and picked 15 conditions that were the most in the -- expensive conditions, and with mining companies committed to shoulders, hips. he found the best places to get those procedures done in the midwest, and, by the way, all of them had lower prices than a lot of places they were going and they had way fewer complications , etc. the problem was getting the minor from wyoming to go to denver or other places. they used cost-sharing in the plan from the -- a self-insured employer can do that stuff, but they threatened the local monopolies with i was in my group over here unless you come back. that is a brutal form of reference prices. in my view you have got to let

that stop go on and encourage it. the guy told me the biggest problem he had was getting the guys from wyoming to go to denver, because they were afraid that they would get robbed in the parking lot when they came out. [laughter] >> if i can follow up. antitrust policy can be beefed up. but that is not going to be -- it is very cumbersome. it is not paying any attention to these combinations between hospitals and physician entities, which i think is a real concern to me. but there are a whole range of things that are market oriented was either come as len saying, can be done by purchasers, payers, or they can be facilitated to governments. for example, one approach is a tiered hospital network which is very difficult to get off the ground because prominent hospitals can say put us in

the best or only one a contract with you. massachusetts passed a decisive to ban that. there are real opportunities at the state and federal level to not necessarily take a regulatory approach, but to take action which actually fosters, freeze up market purchase, and another is austrian physician organization -- is fostering physician organizations. aco program, the it has special provisions to encourage he smaller physician led programs into the program. we need more of that. >> i'm with the international association of firefighters. the replicas concert is the cadillac tax rate when dr. ginsburg pension placing the tax, -- mentioned replacing the tax, with the exclusion of employer-provider health care, it was the first time i heard

that idea, actually. i'm intrigued by that. on the theme of encouraging good behavior, discouraging bad behavior, actual effects on employees, insurers, what it means, i am interested in hearing about that. in addition to the political realities of whether that is something that has legs or not. primarily, how it works. >> i would think from the perspective of firefighters, the problem with any of these approaches, the cadillac tax or a cap on the exclusion is that some employee groups due to the nature of their work or the nature of their workforce are going to have higher medical spending. that is a challenge of making these policies sophisticated, sensitive enough to adequately recognize that. and this applies both to the cadillac tax and to an

bpc reporte, and the had that. one of the most concrete things is the difference between the two is the way it works out, the cadillac tax is effectively a de facto cap on premiums. you give them the fact that the insurers cannot do that the would it is that they have to charge so much more for anything above the cap, they will not do it, and that is really much more limiting than the approach which is just dealing with the incentives and saying you can have the policy that the higher premium, it is just that you will do it without tax subsidies for that last part of the premium. >> there's a difference in terms of the impact, and as you pointed out, in terms of the employer and employee. as you might imagine, as paul suggests, depending on the cost

of the plan, the industry, the group that is covered by the plan i'm at the nature of the plan, it does have a differential impact. you might imagine that a large employer plan, historically, large union plans, there have been a fair amount of opposition to these kinds of changes. when you look at the political realities, those are stakeholders who would have some strong views on this question. great. we're down to our final couple of questions. of thishad the majority conversation focused on areas of consensus and have steered pretty clear from the affordable care act. -- let's bring it back to that specific topic. this russian asks whether the -- this question asks whether the addition of millions for under the aca poses an additional hurdle for health care cost

control. i might ask folks to think about if there are additional opportunities embedded in there as well. now that we are enhancing the poll that will be insured under the aca, whether in the private marketplaces or in an expanded medicaid situations, what are we facing additional -- in additional hurdles? >> rachel, i think a major positive of expansion of coverage is that i think there will be fewer concerns on the part of providers that if they do practice more efficiently, if they limit hospital admissions, this is an environment where you can do that and will not suffer as much. whenever providers are very busy, presumably they're much more receptive to ideas about having to practice more

efficiently. you maybe see it in hospitals. if the hospital is worried about empty beds, it is going to be different than if the hospital is worried about i am bursting my capacity and i do not have the capital to expand. >> that is an excellent point. i would also suggest when you get right down to it, what the law does, in my opinion, is not all, butmore, many more players in the system on population health as opposed to taking care of me and mine. toe your car all insurers take all comers, you have a different world. that world has not yet come to be. it will come assuming the website will come up in 2014. that will be a different world, a world in which insurers will have to change their business model, and their results model will move from partially, and maybe in some cases, mostly risk

selection, to helping all enro llees five value in the system. there will be a live in aggregate spending. yes, total spend will go up in a blip. because we are going to face in medicare performance, it will take four or five years for the whole blip to begin. the key variable in all of this discussion is the rate of growth of costs per capita, and in my view if you have more players the kazakh population health, -- more players focused on population of, you have more providers taking the lead because they will not go broke, and you have more plans focused on value, that allows the system to deliver value and you have more people interested in developing incentives for that value be to be sustainable by providers. it is easier to contain cost of the long run with everybody in. >> i think this is one of the

areas where it is going to be an interesting scenario to watch between the state level and federal level and what occurs in ofse different pockets expansion. certainly, with respect medicaid among we have seen in recent years a large majority of plants for their existing population ine chosen to put them managed care arrangements. in the course of the conversations around the new expansions in the states that have chosen to go with a different strategy, and with those that have chosen to expand, again, the states have thought out and are looking for opportunities to essentially organized and paid for services in a different sort of way. you might imagine with the increase, if we looking at 8 million people coming in successfully into medicaid expansion in the coming year, that there will be greater pressure on the states to look for those opportunities. the enrollment to the exchanges

and the exchange-based fans lent itself for insurers to look for insurers to look for methods to finance care any more efficient way. one way might be the way to construct their networks. the point he made earlier that we are only beginning to see what these plans are going to look like, the rates they're going to be, how they are going to organize services, what tools they like to be centrally organize that care and keep certainlys down, and the uncertainty about what that risk. to look like, because of the slope enrollment is going to because of the slow enrollment will complete things. it will be a couple years before we see things play out. the underlying insurance regulatory changes to put pressure on them, to figure out how dimensions -- how to manage this publisher differently. there are opportunities, but friendly some challenges.

before i post less friends -- before i post the last russian, there is a blue evaluation shaped -- she. i would ask that you fill it out. the last question has to do with 30% of patients accounting for health care costs. the question is, how do we balance between targeting this high cost group first and benefiting the other 70% of the patient population so that they receive better outcomes in high- quality care? >> those are common themes and common strategies. if one can imagine figuring out how to manage that population that are sure nearly expensive, that that can only work to the benefit of the general population in terms of how we

organize and think about services. there's no question that there is increasing attention on the duals, people who are eligible for medicare and medicaid. they are costly. there our efforts to look at the relationship between the state and federal governments in finding ways to finance those patients. that can only benefit the broader conversation about how we think about the ways we organize and manage people over tinuum of care. >> i would look at what real plans are doing, and the medicare demos are doing. what you see is i would say three kinds of patients they are focused on. there are those that are really sick already and you do the best

you can come and that is care management and full speed nurse manager at the side. then there are those who are in bid position that use a lot of services, but they can be much better managed if they were coordinated. that is where people are throwing the new infrastructure. then there are most of us who are healthy most of the us who are healthy most of the time. we don't need much. it is about consumer service there and then about preventing that 70% from getting the condition or having the condition deteriorate. it is about monitoring. you do not want to ignore them, but they don't need near as much infrastructure as the 30%. but they are finding is that they do better on roi if they focus their infrastructure on those that are in that 30%.

unmindful of not the ones that come in, and if something happens to you and you get in the group that needs more attention -- but you don't need that much attention. most americans would balk at that much attention. i don't think it's that big a problem, as long as we get the infrastructure. thanking join me in our panelists for shedding light on areas of consensus when we talk a lot about differences in this town. thank you very much. [captions copyright national cable satellite corp. 2013] [captioning performed by the national captioning institute] >> good points.

i am, sincerely karen l. haas, clerk. the speaker: for what purpose does the gentleman from massachusetts, mr. neal, rise? mr. neal: mr. speaker, i ask unanimous consent that the gentlewoman from the commonwealth of massachusetts, the honorable katherine m. clerk, be permitted to take the oath of office today. her certificate of election is in front of you. there is no contest and there is no question that's been raised with regard to her election. the speaker: without objection. will representative-elect clark and the members of the massachusetts delegation present themselves in the well of the house and will all members rise? and will the member-elect please raise your right hand. do you solemnly support that you'll support and defend the constitution of the united states against all enemies, foreign and domestic, that you will bear true faith and allegiance to the same, that you take this obligation freely without any mental reservation or purpose of evasion and that

you will well and faithfully discharge the duties of the office on which you are about to enter, so help you god? ms. clarke: i do. the speaker: congratulations. you are now a member of the 113th congress. -- ms. clark: i do. the speaker: congratulations. you are now a member of the 113th congress. the speaker: without objection, the gentleman from massachusetts, mr. neal, is recognized for one minute. mr. neal: mr. speaker, it's a pleasure for me to introduce katherine clark with the always important reminder that there are fewer than 12,000 men and women who have add the honor in american history of taking this

oath. this institution has been home to presidents of the united states, members of the supreme court, members of the united states senate who have gone far and wide in helping america to succeed every day. katherine clark is one of those individuals who has now joined this important and august body, succeeds, again, a very favored colleague of ours who served in this institution with distinction for 37 years, senator ed markey. mr. speaker, katherine clark is well-grounded in local government, having served at the school committee level. she served in the legislature as a member of the house of

representatives and as a member of the massachusetts senate. she has also served time as a prosecutor. she is well distinguished in the state of massachusetts and won a very handsome victory. it's an honor for me to submit to you for the first time the honorable katherine m. clark from the state of massachusetts. . . . the speaker: if the gentlelady ill suspend the speaker pro tempore: if the yeal will suspend. the house will be in order. the gentlelady may proceed.

ms. clarke: thank you, mr. speaker. leader pa lowsy, congressman neal, and the massachusetts delegation, and all of you for this very warm welcome. thank you to my family and friends who are here with me today. my husband, rodney, and my three sons, adyson, jere red, and nathaniel whose love every day makes me the luckiest mom and wife in the world. my parents, chan and judy clark, i thank you -- thank them for the love and support and teaching me even when times are hard approach life with gratitude, optimism, respect for others, and a sense of

adventure. myelin yause -- myin laws, i'm so grateful for all they do to keep our family running smoothly and all the love they give us. and my brother, john, and his partner, justin, thank you for being here and for all your support. and i'm so grateful to the voters of the massachusetts 5th congressional district for their confidence and the profound privilege of representing them. senator markey, you set a standard of excellence during your time in the house. i look forward to carrying on your work for the people of our district and partnering with you

and the entire massachusetts delegation to move massachusetts and our country forward. thank you. massachusetts fifth from revere to came brinl, waltham to freedomingham is home to some of the country's and the world's most respected universities and innovative companies. we are deeply -- >> mr. speaker, the house is not in order. the speaker pro tempore: the gentlelady will suspend. he house will be in order. ms. clark: we are proud of these incredible institutions, but what defines the fifth district is its families. and as i have talked with families around their kitchen tables, i found they are just like mine and i'm sure they are just like yours.

we are teachers, small business owners, c.e.o.'s, and machinists. we work in stock rooms and board rooms. we are recent immigrants, and we are desendents from early american settlers. we are of all political ideologies and, yes, deep in the heart of red sox nation we even have a few yankees fans. what unites our families is they work hard, play by the rules, and what they ask in return is a fair shot at the american dream. our families want to find a good job, send their children to great schools, and count on a secure retirement. they want to know that the issues they talk about around their kitchen tables are the issues that we'll talk about here in congress. i am honored to join the

massachusetts delegation and represent the peoples of the fifth congressional district in this house of representatives. i look forward to working together with each of you for the families of my district, the commonwealth of massachusetts, and the united states of america. thank you, mr. speaker, and i ield back my time. the speaker pro tempore: under clause d -- under clause 5-d of rule 20, the chair announces to the house that in light of the administration of the oath to the gentlewoman from massachusetts, the whole number of