could buy hotdogs and an order french fries for a dollar a pop. you won't be able to buy that now. >> i appreciate your call. it for us today, and want to make sure that you come back here tomorrow morning when joined by associated reporter darleen superville. and then look at the best and ads of 2014.gn we hope you have a great saturday.

>> a look at the cost of health care and the role of accountable care organisations. seized man's he coverage of the kansas governor debate. on wednesday a panel of educational experts will agree that one challenge to the common store in issues to right now is a lack of material available to educators. the panellists analyse the cons of the initiative. this is 90 minutes.

afternoon everybody, thank you, welcome to the american enterprise institute. as we talk about back water issue that no one is really talking about, today we are about the common core, an issue that has an incredible amount of salience in the media and in politics and we have three outstanding panellists to discuss. introduce them to you that is a veteran education reporter education week, she co-authors the curricular matters and if you want to get up to speed on the common core and how it has been playing out in classrooms the country, catherine

and her reporting has some of the best. that would be rick's director of policy, he actually participated in the intelligence debate on the topic embraced the common core and he has a new piece leading national issue of affairs in title " how the common core went wrong". in 2009 he was the strategic initiative director of standards investment and he led the ity where development of the common core in the 45 states in the district of columbia.

we are going to forego the usual speechmaking talking points that begin these con slabs. we are going to-- conflabs. i want to start with the laying of the land and catherine i think you will be the best to give us an overview. we are hearing across the country that schools are implementing the common core what does that mean? >> well i wish there was a uniform answer for the whole country but, you know, things they are, there aren't. having done me that a lot and is still gaining a sense of what they are meant to do that is different, at the other end you've got people plunging in and making a lot of deep changes.

as you know i spent eight months hanging around the district of columbia sing what they are doing. have a lot ies, you coming ects that are from grassroot levels like nevada, it has they are ed that making efforts. they are going to create resources themselves, it is all place and it shows from the cep report that a lot of districts are behind on a lot of the pieces are going to make this work. two thirds of them are putting things into practice. >> i do want to add to those of you that a following on home

on the live stream or for those of you joining us on c-span the conversation is also taking place on twitter with #whatnowcc. i will do my best to follow along while we are talking. to get in line for these new are being rolled out, using the great mass that education week other large d, the consortium has -- doing their own thing.

where do you see this going? >> thanks for inviting me to be here and catherine your great on this een topic and obviously you are in the details. if we had said in 2010 that we states participating working together, no one would have predicted that, we had 50 riding their own tasks so, i think 26 is a real progress. there are many that have stepped away and there are a number of reasons why, the federal involvement in this has not been helpful in every scenario that we have been following. you see any sort of push back around testing has been rooted in the fact that the government involved in the funding, and for folks to adopt the common

core standards. a group of states taking part. going to if they're i think we er, need higher standards for kids in this country. had we make sure that the assessments are at a level that are actually different than what we were doing before. your i would love to hear response on this?

is a positive development or risk further long-term core? is a great question, catherine's work on this has been invaluable, one of the reasons we are where we are is because the common core felt like a surprise to a huge number of americans. remember catherine called late 2009 probably early 2010 and i had just blogged about the poor jobs and education spaces. catherine said you don't really care about this do you? i think most americans knew little about what it meant. i think catherine has done a remarkable job but obviously

they are speaking to folks in education. i agree wholeheartedly with chris that i am form higher standards and i don't know anyone who is against high standards. i think the big part of the question is how confident we should be that the common core standards are higher. for me i don't have a problem the common core standards, i wanted to be higher and better especially in practice and i am concerned that some of the stuff that goes along with common core, like the infinity for closed reading. like to see y would time to see how it shakes out before i would see this as a train we are all jumping on. that's the reason i think a

number of states edging away from the common core is a good thing. i think 15 states, may be 20 or maybe 15 states would have gone ahead and on the common core on their own. they would have figured out how to do a common assessment like in new england. a hat we would have seen is truly and genuinely statewide effort and if it was working in other implemented well states would it have wanted it. unfortunately that is not what we are looking at and it has exposed washington so it has been fun to argue how we have got here but also what we're talking about today is what of the moving ies forward constructively. you and rape, agree

that the government has caused a lot of the problems do you see an appetite on the half of common core supporters to push back more vigourously against the common government. to take a more proactive stance? >> i think it is pretty clear, that most of us, i cannot say all of us f us but believe that declaring our independence is critical. how as governors we step into this place, the hardest part do not have -- its fundraising issue. have passion folks

and money. the biggest thing is figuring how we land this. i think the shift in the common core are based on research and they are also based on what teachers tell us they want to do with their kids. this sort of -- i can the t you there wasn't as it is in ere is 2014. there is something about the standards that are really worth holding onto. i am happy to keep talking about it but i think the

biggest thing is how do we land this thing in five years so that teachers are able to teach a higher standard and kids are graduating from high school at a higher rate. we are making progress with kids, we can debate all we want in washington whether or not this is a good thing. more kids are ready to go on to college. this is important. this is the stuff i don't want to lose, i can lose the other staff. be interested i'd about the we talk common core, take a couple of minutes and drill down to some of the sticking points, and understanding what is happening. the first issue that united people in the political right with data privacy. i was wondering, catherine, in your time in school, how big of a concern was it?

>> i am not the p person to ask about that because we have had other reporters focused on it is a n i have, but concern. this whole debate sometimes reminds me of when you go hear the and you noise above and it goes quiet. this is not the stuff that people are talking about. out what that re means

surveyed in ent sue the district, there is a much higher response rates. they feel the backlash but in terms of doing the work that's what i hear people talking about, i don't know about data and school so much. >> i think there is a dynamic here which is, i think catherine's takeaway would apply the much across the board will meet about special education, when we talk about we eral grant requirements, talk to educators. you generally don't hear a lot of grumbling about this. you generally hear people trying to make this stuff work. when it comes to federal grant requirements and when it comes idea, we about

often provide unreasonable solutions. me this is a r good difference where reasonable people should be able to argue about it in a way that we haven't had much. at common core standards, across standards, they are not different from what a lot of states had on paper but there are a lot of stuff that go along with the common core. some common core advocates common core is smuggling because there is a 57 word little appendage there. those who like the common core celebrate the closed reading.

it is something that teachers are encouraging to do 70% informational text by the time are in high school, not in english class where you are supposed to be doing a lot of reading. i am personally unpersuaded that epa manuals is better chemistry instruction then doing labs. i am not opposed to these things but i do know how it's going to shake out or be good fit kids. to me therefore, how do we not do this as a 40 odd state let riment but had we states like kentucky, where you actually have deep commitment to doing this and doing it well, let them try and let others of us stand on the sidelines and see whether this works out. >> chris, is there a way to do that? >> we are going state-by-state right now so there's nothing

forcing the state to stay in the common core. there are incentives, but there is nothing preventing from doing review processes, doing what they want do with it so, i think the narrative about what the standards are, it is silly. of course we want kids to be doing labs. i think it is a false distinction, we want kids to be reading more complex texts, a high level of understanding by they leave high school. i also know there has been a process like this in a country with a massive amount of him and is that we've had. they are fundamentally different from the state so i disagree with that to.

another issue with catherine, who touched on this. one very attractive feature of common core was the idea of a nationwide marketplace for material, so rather than just having your alabama textbook market them maybe folks all over the place. catherine i was wondering if talk about these challenges. everything that we hear with a few exceptions would suggest that the publishing as we known it, hasn't done a very stellar job of changes in its materials.

there are some things emerging that look promising but it is not, it is sort of few and far between. had been deep inputs, i mean, future organisations to get inputs now, that speaks for itself but i think materials are being at the grassroots level, but that's one of the most universal and consistent complaints that shows up in research and that we do in our reporting. the stuff is junk. >> there seems to be a strong incentive for folks to take the same product that they have always had an slap common core line on it. are their efforts at work to try and do something about that? to help schools sort through that are out ns there?

one organisation out there, it is brand-new and they begin to look at the alignment for materials. i don't think we should do anything but acknowledge the fact that we have been slow to provide teachers what they need to teach the standards. i think we have to then, start move that point and quite frankly catherine's reporting is very clear. you cannot say that standards at that much different and also say we need way different materials. was an eve there significant changes, and we need better materials. that is something we need to acknowledge. we're going to have to get better materials for teachers.

>> i think this takes us in a good direction because at some point in the near future at the rubber is going to hit the road, and the parser are aligned to this standards consequences will be attached to them. looking forward, where is this headed? there are concerns that have the do not necessary materials. had used that planning out? simple truth e from me, if my employer tells that they want to do more to hold me accountable for my performance, that is reasonable, i don't have a complaint about that. they want to tell me they to change the way they

me do my job that is going to look as if there is something on my back.

you see this in a lot of places and frankly this takes us back to something chris said a couple of minutes ago which is these federal induced timelines. what we wound up with were federal political timelines for the rate at which they ought to be making the transition of common core and transitioning to teach a-based evaluation. i think the way forward again is not necessary talk of blanket, you know, hold-up periods everywhere but accountable republic officials in the states ought to be making decisions. there are some states that seem to be covering common core very well. there are other states that are being dragged kicking and screaming and i don't understand why we imagine this is good fit kids and children try and force this from washington so, to me, a real simple place to start is by when you are hat doing, when you're trying to you are he way

evaluating performance, there are timelines are based on pragmatic considerations and there are timelines based on political considerations and i think we spend too much time working on political timelines. >> one response has been through waiver processes, it is push back the consequences in which states have to start using these tests. are we expecting to see more of that in the future? is that productive strategy? are nodding ike you in agreeing. how do you set these timelines? >> we are here to talk about the common core and is very tough to separate these issues evaluation cher issues, i think state chiefs and state governors need to decide where they need to go. it needs to be in the hand of the states, quite frankly the scenarios are so different. i think a single federal timeline was always hard.

i do think so that we have seen real commitment from states about stepping into this and we hear the most from the having the are hardest time, they are moving forward in a positive way. i don't really care that much about the evaluation but i do care about teachers getting better feedback. i was hopeful that that initiative will stand on that spot not the spot that we can use the examples recused. i don't see evaluation being taken off the table but i do think that states and districts are going to have to decide how to do this. >> catherine, your experience in schools and districts, as sort of landscape changes the teachers, how do they see themselves. being ing the goalpost

moved on them? are they being part of the process? how are they responding to all of these changes taking place at once? >> i think they are just trying to figure out how to do a good job and seem very frustrated -- lot of my time has been spent hanging around the district. some of them are prig cited and some of them are feeling overwhelmed. there was a sticking timeclock, they always think there is a time on the wall. they feel there is not enough time to do something they need time to do. they have very little support.

that is the piece i keep running across when i talk about the schools and teachers. maybe we had the standards that we don't have good instructions on the materials worse very little strategy for understanding how to deal with kids who have the greater needs, who have the greater way to go. >> absolutely. there was an interesting story today in my google alert for the common core which fills my inbox every morning with interesting things. it caught my eye because the first common core year louisiana's public-school grades improved slightly. when we increase the standards we should expect to see larger and larger students failed to make the provisionsy. as i read into the standards,

how could this be. grading of the tests of the new e impact standards, acknowledge though the questions were tougher this year the grading was easier get few items o right to pass the basic than they had to do in 2013. guard ant to be on against this back standing,these lower standards. >> we would have a repeat of what happened essentially stay s are allowed to there in standards.

we have to guard against that and there are number of ways to do that, first of all, as states are thinking of setting a common performance, that is a really important piece of this. in a he stateside to go different direction they have to be thinking about what that means for their kids. their kids are not able to achieve at the same level as the other 16 states in that group. i don't see that part being a huge problem. it is the individual states that are given their own assessment to writing their own assessments to the standards and we are going to have to continue to work with them. i see different attitudes about the assessments and i did five years ago, for five years ago states were simply tried to do as cheap as possible. states are recognising that they need a higher quality in grade against those standards. last thing i mention, i

think it needs to be looked at the state individually. one year ouldn't be a in consequences like in kentucky. there are other states that need another year and need these test to roll out free year before there are consequences. this should not be a single conversation in this country. >> earlier this week there was a bloomberg headline. that put out an ad out a quote. i wonder about changing this. when these sort of laggard states don't live up to their standards, in a way are you

cutting the needs from the folks who have had to make the tough decisions to toe the line? >> kentucky's superintendent the more outspoken leaders, terry holliday said, wait a minute all of this is making it harder for them to do what they are doing. if you try and drag everyone on the common core train instead of letting the states want to do it, do it. you've got those riding up in first class and you've got another state riding along in coach and they are kicking and screaming and the noises affecting everybody and making this more controversial for the states want to do it. let us also be clear, that part of this problem that

making it clear that it is something that everybody should be doing you have wound up with all sorts of design complications. one of the reasons we needed the common core was because we had all this gameplaying. states would funny go without cuts scores and take lousy and easy test so nobody was getting good accurate readings on how kids were doing. to that of course that people can analyse. they recommend a 60 day testing window between schools and states that started different times. there is also a tradition when it comes to testing of school districts pushing back test because it means kids get a lot of extra days of instruction and the schools look good.

you would make it a condition of joining a testing consortium. they are going to look at the master schedules and work with the folks. that was part of it because they are trying to get as many the states to play as possible. you only get to be part of our if, you onsortium actually be -- agreed to be part of us. and get as as to try many people as possible. i am ant something we

personally fairly despondent on this and suspect that in more than 70 to 80% of state is going to fill in 2018 exactly it felt in 2008. >> i just need to get in on this. >> so, first off, i couldn't disagree more about the testing window thing, i can give you i think the le, state all start at different times, they are trying to test technology, i think this is the only decision this consortium could take. of course people are going to push as far along as they can in the testing window, i don't think that is a problem. i would just add, the bigger question is whether the state to stick together on this in terms of at the end of the day they are giving these tests getting these results we can show as a country, we will have a more fair benchmark.

i just think that is a real end, the and in the common core was never built for the 50 states. we never encouraged 50 states that are coming along kicking and screaming, i of any other states that cannot get their legislator to pass that. we still have 43 states left. if so many states are kicking and screaming, there are only two that have left. >> i guess one thing, brick, it seems that you're highlighting catch-22 here, if you want more people to

participate in something you have to lower the requirements of what it takes to get in but the whole point of being in it hold each other accountable you hold high expectations. i would how you respond to that? if you need people to be in and you worry , get t backsliding had you out of that? put systems oing to in place? >> that's the thing that i think rick has really hit on, what of the structures that the consortia can put in place, what are the policies that we can act as a group, not federal but as states working together to make sure that in the long run the consortia. is successful. you are asking what is going to be different 2018. here, challenge

how any of this strikes you? one instance i would like to lay out some to non-negotiable commitments. they will look at start dates and they will tighten the a 60 day window but within a given state should be much tighter and that is something those governing boards should agree to and you should play by those rules. they should have manned the tories scoring schedules, said the school should be mandatory and not something you can be a member of and still opt in or opt out of. we don't know yet how translatable the results are further than the computer-assisted assessment from kids doing it with paper and pencil.

i personally suspect there going to be some issues. i would like states to be required to use whatever translation required. to me for instance the point is, i want to see if you're going to be part of a consortium to ensure integrity, i want that mean something. i suspect that means that some states may say that is not for us, and to me that is a good result. to katherine, i would like hear your response on that. >> how does that trickle down to this call to the teacher? it's a o think situational. it does occur to me that it might not feel like a mandate from washington, in the current environment what would that be

like? one more thing handed down is expected to do -- when about the common core, how true is it that there could be a russian state that want to get out when they can. they do have waiver cash. have already seen what the us department of education did in revoking one waiver. or these things are still operational and clearly the environment is still heavy with that. i do know what requirements within a consortia would do. seem to me that one of the questions about the test scores is what you are you going to do about them? you have to report them.

they all have to publicly disclose what they look like but then there is a question of what are you going to attach to them? i.e. going to peg high school experts? that is a whole different thing than we are going to take a whole different school that political effect of could be different, what part of the higher ed system is going to be affected by the scores. a whole like those have lot more, hanging in the air, than this question of the testing window. the i think part of challenge here is that if we have spent all of this time and passion in the last several years and the next several years doing this, and we wind up with a good face group that

things are going to administrate the common core assessments in smart ways and the public officials are not going to fight the results, that's pretty much where we were in 2001 to 2009 and i'm not sure that any of this will worth it if wind up with tests written by the consortia. i actually, t is, my answer on all that you have raised, i don't want the feds touching on any of them. for all of this took been worthwhile i want an idea that these results are going to be, feel much more like the sats. be so chris i would interested to hearing, what is called for is some sort of

not the g body that is government federal. efforts to create that, is something to be done to create a body like that? i agree with rick, making that there in s these two groups up is really an essential part of this. with states just giving tessa being okay with it and not really committed to sticking together in the group, i would agree with that. i don't know what the governors look like long-term issue we have two resolve.

writing another set of standards for the country is

going to be difficult at this point, there would be a lot of controversy and i don't think we would be able to get through that process especially through washington dc so i do think the states need to own this process, but the states are working together going to have to figure out how they up their standards. that brings us an elephant in the room. >> there is a lot of conversation over the last couple of months in these midterm elections, there is another discussion that could be had. i was wondering if you could share that an talk about that and its implications? >> it turns out when you look at candidates for governor and senator on the website only three of the 35 democrats are mentioned in the common core. only 10 of the 35 republicans running for republicans mention common call. is interesting is half mentioned the common core but you can actually do very course of the common the senate. i think that the bottom line here is what reason this is been so talked about because it got wrapped up in federal politics and things that looked very good to the quote unquote reformed community in 2009 when president obama was holding 65%.

i think that is true of several elements that got wrapped up. the opportunities for folks, i am not opposed to the common core i just want to see out these things shake for re we jump on this and folks who are confident this is the right way to go, i think one of the opportunities is how you separate this from washington politics where the issue the governors can address. it says the re

federal government will not touch curricula so there is is it hole question about touching standards? senator alexander said let's close the door. i think one of the real opportunities critical duty to was the folks who really embrace the common core and embraced as a state led initiative to really jump on that train. for them to be saying that look, this is the kind of everybody can agree on, whatever has happened in the last five years has happened. let's make it clear that who is elected president, this is something opposed to them to make decisions. for the department of health whether they are not

behaving properly. >> i would love to hear your thoughts? >> i haven't read the washington post but it sounds interesting. i would just say my experience in the state mirrors what rick has just said. further in lot of the media with few people in every state about the common core but when we actually start talking to people, that aren't actively involved in politics, there is a lower level of understanding what the common core is. a lot of people don't the common core is, half of the country don't even know what we're talking about here, and there is a real us to start for explaining.

the federal push on this would and eally helpful for us a federal role s in education and it should be one to make sure states are not doing bad things to kids in terms of equal opportunities and things like that, but i think in this case, i think rick is right, we need to make sure that it is clear that states made the decision to raise their standards and they need to continue making them. >> before i turn it over to the audience and again for those of you watching at home, free to tweak me. -- tweet me. what you see is the biggest threat of the common core moving forward? >> the biggest threats, i

think the transition to the test will be the big challenge. making sure that we can honestly tell kids how they are doing. can i have the second answer to? >> i think over exuberant advocates, i think the more folks like chris out front about the common core and addressing legitimate concerns, i think the better its prospects. saying re folks that are it is also, i think that is a recipe for people to do better. lightning round quite literally. i appreciate it. you must write about education.

what does success look like? what does winning look like? save katherine were to write a 10 years from now,what are the types of things that had to have happened? in order view to write that article what type of things would you have needed to have seen? >> i guess, i would have to do, i guess it seems to me from district and perspective that from the state in the political sense, it seems to me they would have to have some sort of evidence that were really doing better,

and in particular because it is that i'm of thing interested in, the kids that are actually more behind have made progress. opportunity gaps close and achievement by some standards of measurement whatever that is is better. college success rates in other words remedial oration, that is made an impact of success in higher education. i think often gets forgotten is the original intention of this. college and career readiness. if there is no impact and no buying, what was that about?

>> i think the outcomes that catherine alluded to in terms of employee satisfaction, in terms of kids performance, i think the second one would be contingent on resolving some of these questions about what it means to teach the common core? i get a lot of emails from folks who are frustrated. we see some of the really outrageous stuff online and other stuff that say it is crazy and that is not at all what the common quite trying to push. this has to be resolved. and frankly i'm not sure how to get sorted out. it has to get sorted out in ways that dogs that encourage destruction. >> we have got some work to do teachers talk about mathematics, we really

re-entered a maths world. i think we have been a major way n that dy towards the idea kids need access to higher education. i think we have had a measure think cess on that and i that is largely thanks to others that came before me. in terms of what we are towards, remedial oration rates, kids are playing further classes that they should have had in high school, that needs to drop. more kids graduating with more meaningful credentials.

the want to tag onto lightning round there. some of ou worry that the advocates are setting themselves up for sale by setting a high bar? the common store seems to be the single greatest thing happening to education in america. could do great things, you could talk about what britain talked about could conceivably be achieved are you worried about that? >> i can only advocate the way advocate. we all have our own style. my sense is that this is a big deal and we shouldn't under

that we are e fact asking more kids across the country this year. sec duncan has done a pretty good job and i think his push to look at standards and look at assessments they were all okay pushes. am i concerned about the way we are doing this? rick and the others can debate that. we care about kids getting to these standards so we are willing to have what discussions it takes to realise the standards. >> i think we're going to turn to the audience now. i have already been getting twitter which on is outstanding.

for those who are tweeting i'm few g to try and combine a of your tweets, because i see a lot of them in the same area. for those of you who are joining us if you haven't been to in aei education event before we generally have two roles are questioners. that you identify yourselves and number two that you actually ask a question. we are trying to go light on soliloquy and high on questions. a lot of people want to ask questions and i would like to get to as many of them as possible so if you do get that nice think punchy questions.

the first question that i have seem different variations of, maybe we'll start with catherine, a lot of people have been asking about the effect of core on non-tested subjects. asking about been the arts and about a lot of other issues. in your experience in schools have you a comments seen any evidence of narrowing of curriculum or b, any evidence of fear of narrowing curriculum by focusing on what the common core does by pushing out these other subjects. >> i would just annoy you by saying neither. been i've seen, there has a lot of attempt by hung out to i have implement these cross disciplinary expectations of the common core. there is a huge misunderstanding in a lot of places as to what that means.

they are not social studies standards, their literary standards specific to discipline. how do you deal with scientific material had you make sense of that? i have been places that have really tried to do that and they're trying to involve teachers in doing that. i saw a lot of work in kington town in kentucky. >> so those folks do not seem concernedabout a narrowing. i mean, the narrowing was kind of happened after no child left behind. if anything, there was a broadening to that. everybody in the building was having to get involved and how to teach literacy in the subject. >> and i know, rick, you have expressed some concerns. comes . again, it just

back to -- coming court feels to me like a pig in a poke. i like to see things before i buy them. i der no child left behind, do not think coming core changes that dramatically one way or another. a pothetically, it creates collaboration between teachers, which is going to actually deliver on the promise that it is going to help -- you know, sure instruction is robust. public schools, to subsume social studies and histories under language arts that is an indicator of something i worry about. i think it is easy for us to about that for sure, we're

going to carry over into other courses. and that may or may not lead to good instruction. anything that see convinces me that it is going to lead to rich instruction. >> i mean -- i don't have much set dd other than with any of standards -- i think whatever standards they have, it has been happening in the past and narrowing. teachers have ce, told me that this has given a space rather than less, but i'm sure that there are places where this is not working exactly as we would want to. every state has science standards, too. if teachers -- if we are not teaching to the state standards, that is a problem. i hope we are aand, at least as for the common core, we should be advocating for

those things as well. >> great. let's go ahead and take one from the audience. identify yourself and then ask your question. >> from national review. i guess the question is mainly to or at least i would like start it with, soda from a neutral standpoint. i'm going to give an example of what i mean. but the question is -- are you that teachers are finding tthat they even understand what it is that the standards are asking them to do? or are they finding that it is of educational bureaucratic gibberish? the reason that i ask this -- will give one example -- >> are you going to talk about -- to quote one ing thing from an introductory part

specifically from the common core. is that is -- it says this telling that features they need to get across to the kids. student should have two abilities. they should have the ability to abstract ualized -- to a given situation and represented symbolically and as if they have a life of their own without necessarily attending to the reference. the ability to contextualize the pause is needed during the manipulation probe into order to the reference for the symbols involved. what does on is -- that mean? >> our teachers able to translate that into practice? >> exactly. >> catherine, have teachers

been wrestling with putting standards and practice. >> it is the

the level of anxiety around technological readiness, i thought it would be more of a dramatic problem, but it wasn't. there were small glitches. that said, it is pretty well-established in the survey that districts have long way to go -- a lot of them -- to be ready.

especially for bandwidth issues, less on hardware. >> so, rick, how do you respond to that? does it make you nervous? >> anytime -- education is filled with artemis. are around who before behind, there was on the back and forth among those of don't have real jobs to talk about these things. than educators are like, yeah, going to work out. hesitant on little the surveys of district leaders teachers, but, i think one the big tech challenges is one of the reason folks are to get kids assessed is because they are using a medley of devices. know a lot ctually about compatibility. you hear a lot of different stories.

kids who have never done drop and click, kids were using different devices. of , you know, d problem for been a national assessment because they roll up in their computers and the thing is pretty tightly orchestrated. this gets to the question of how much confidence we should have in the reliability and validity. are because i think people doing things amiss, but because i worry that -- because this is an engineering project -- we're paying more to get it done. >> just quickly. since the educators are think that is right, and i think that d.c. is full of customers -- so,

we neeed to be attending to as we go forward. in oregon in 2000 wheen we began shifting to online assessment. i was the assessment director there. took us five years to get every kid online in the state of oregon. was 13 years ago and oregon right now is giving other assessment online aand has been for seven years now. i think some states will have it easier than others. also think that this one you transition will be very hard. like i said, it took us five years to get unlimited transitioned. think we'll see some glitches in the first year or two, but i they will be livable. >> i think we can take one from the crowd here. you'd be so kind to wait for the microphone to show up.

the i i am karla from center for reform. i think, you know, the common core debate has been a big distraction from the largest elephant in the room and that our schools may not be even equipped to do this job. you go to a really good school, they don't really care about common core. just get it done. focused more we be on fixing so the teachers to the freedom and flexibility to figure out how they run their classes? >> rick, i think that is probably to you. >> great question. i think there's two answers. one answer is that i think this i -- this is something which think is partly a thermometer and how one feels about the common core. as for my friends who were very enthusiastic about the

potential the common core, they say that they care about ultimately we t have classrooms to change leverage. least the second issue, which is the disconnect between those of us -- especially who hang out inside the beltway talking about schools ions and how are run -- and folks out there to who are talking catherine are talking to, who think that it is a big disconnect. as it has been somebody, as you know, who thinks a lot about governance issues. they matter a ton, but i think it is then easy to be what happens in classrooms.

and for me, the reason, core i tter so much is because think somebody's conflicts these very -- some of

conflicts speak very instructionally -- it also plays out immediately for the kinds of decisions leaders make, for how dollars are allocated. i think the enthusiasts were so dismissive of questions and concerns that it really spurred a backlash. and i think that now the backlash is spurred on motives and outliers that we are not asked to having a productive conversation. partly, what i am hoping we can do going forward, is an honest discussion of when does coming core kit in the way -- when does it impede familiees and schools. how do you think this stuff through without necessarily questioning each other's motives. >> good to see everybody coming together and that one. i will take another one from twitter that, actually, a couple people have asked about these is teacher preparation.

conflicts speak very instructionally -- it also plays out immediately for the kinds of decisions leaders make, for how dollars are allocated. i think the enthusiasts were so dismissive of questions and concerns that it really spurred a backlash. and i think that now the backlash is spurred on motives and outliers that we are not asked to having a productive conversation. partly, what i am hoping we can do going forward, is an honest discussion of when does coming core kit in the way -- when does it impede familiees and schools. how do you think this stuff through without necessarily questioning each other's motives. >> good to see everybody coming together and that one. i will take another one from twitter that, actually, a couple people have asked about which is teacher preparation. that teachers -- this is to be too nuts to crack. one, to get the teachers up to speed and the resources that they need. but the other question about getting teacher preparation programs aligned with the coming court to prepare the

teachers -- with the common core to prepare the teachers. feel free to tell the tale, catherine. >> i don't have a tale to tell as much as other reporters. the world hasn't changed in an overnight revolution, but i did want to check with them to be sure. in general, teacher prep programs -- once again, it does very. there are some places that are really looking at the common core and in incorporating it into prep programs, but there's a real divide their. there are programs that feel that is not their job, to prep teachers for a set of standards. it is pedagogy and theory and -- so there are places that do not feel that this is what they do. is not happening there. there has been an allover on teacher prep programs were doing nothing or than nothing at all. there are some good deep -- for preparation in-service teachers -- but lot that is shallow. the respond from the -- universities have a great deal of autonomy. it is more about controlling them or cajoling them. there doesn't seem to be a lever that advocates can pull to get these folks on board. what are these kind of efforts to get teacher preparation programs on board? >> so, the first thing is that school districts need to be more active in the teacher prep programs in the areas. in establishing that we are in our g the common core school district so that the teachers can teach you standards. i think that is sort of an essential piece. whether we have the common core or not, we need to fix teacher prep. good programs out there that need to be scaled.

then there are far too many programs preparing teachers for our schools. i think a

i think a separate lens of this -- we could spend an hour and half talking about teacher preparations and i think that is an issue we have to work on to solve. from my perspective, right now, we need to highlight the colleges and universities that are doing great. we can see a big difference in preparing their teachers. it is not like we don't know how to do this. >> so, rick,do see the common core efforts interacting? >> every five or 10 years, you'll be told that any critique of teacher preparation is invalid because they reinvented themselves. then you go and actually look at what they're teaching and you spent time with faculty and it feels very much like itself in 1995. but they will insist it is very different. they're doing t is different than they can give you chapter and verse. if you sit down with them, yeah, nothing has changed. mike, as you mentioned, universities are buffered. the only way that his teacher programs actually feel priority -- as long as we take teachers were th poorly trained, so long as we take folks who don't know how things particularly well -- it is hard to generate the leverage internally to change what they do.

i think, again, if you think the common core -- chris said a few moments ago that it works on paper, it doesn't matter. i think that is exactly right. about ferred way to think the common core is a commission statement at mcdonald's or any fast food restaurant, they all much the same thing. they want to get to delicious food, prompt service, courteous. may not have or anyrelation at all to your experience in that establishment. actually matters is how the employees do their work, how they are held accountable, how that organizations managed. frankly, it seems like that getting from here to there the common core advocates is that getting it adopted was big political accomplishment. this is why it frustrates a lot

of my friends who think that the common core is going to be good for kids. i want to get these guys to the or 12 mile mark until i feel that this is confident that it is good or bad. they say, wait a minute, we are at the 18 mile mark. they have k that vastly oversold how along the have schools and systems are.

vastly oversold how along the road schools and systems are. >> we can take another one from the crowd. a gentleman here in the center. if you'd be so kind. >> fred from the private public action. you raise the issue before, but it needs deeper discussion. what are the measures that are really going to do it? do we have to be more creativeand what we think those measures are, and are the only quantitative? >> chris, do you want to start with that? >> so -- i think that for us is the problem that we are responding to when writing the standards is that too many kids were going to standards and having to pay for classes that they should've had in high school. it is that simple to me. they were not writing at a level where they could enter their freshman year. i'm sure there are other measures we could be thinking about, click our kids leaving high school ready to do what is next? whether it is college or career training program. i cannot get past that. if we do not hit that number, i think that one is essential for the movement. we have to see more kids being successful. we are seeing that success in just the first three years. i agree with rick that we have a long way to go. i think we are probably closer to two than 18, but we're probably somewhere in the middle. this is still an open question on whether or not we can deliver kids out of high school ready to go. if the standards are not doing that in some way, i do not think any of the other measures would matter. >> this ties into the conversation earlier about narrowing. so, what gets measured is what gets taught. rick, i would like to hear your response to this. do have a worry that even standard seem to say you want to bring in outside content matter in, that they might be strategies developed? >> yes. sure. but i do not think that is fundamentally different from the previous era. i think that is the same that many of us would have long encourage states. to make sure we are looking at how many students are mastering world languages. are looking ure we of passing ap exams.

for me, i do not think it is fair to blame this particularly on the common core. i think that is another piece with a different challenge. >> catherine, please. >> there is a new opportunity, though, and it seems to me that about what talking is measured, we're talking about how it is measured. the assessment tool. as well as what is being measured. the underlying steps. we mentioned this before, but we need to keep in mind that 27 states by using the balance test. the others? well, we will see. it is anybody's guess at the moment. you can independently analyzed how well you think it sucks a balance. we are not talking about

whether he measures also these differently and science differently. we're talking about math. are they going to get deeper and more nuanced or are they not. wait-and-see. we do not know the answer yet. >> i'll take another one from twitter and then catherine, i it back to ly take you, because this is something measured that a measure of success. a number of questions involve students of special needs. when you are out in schools and classrooms that had students of needs or english learners, how did you see them interact with the common core? >> i do not hang out with teachers of special populations as much with teachers who serve other kids. on the ell side. what i saw was teachers tried do their very best and the places t one of

they need most was teaching special populations. the survey data we have seen backs that up. the least support and they have gotten the least insight. there are struggling with how theydeal with kids whose native language is not english. that stuff is a week's own i have seen -- stuff is a weak zone. >> is is your experience as well? >> yes, we have a real talent about what we do with kids at grade level. how do we make sure we're scaffolding so we can make sure children can advance. i think these are all things to be looked at.

>> i think we have time for one more question from the crowd. >> i am roberta stanley, a public school advocate. in retrospect, i think it was a to take for the governors sign this compact and have it of in -down instead another method. >> state schools and governors have traditionally been responsible for standards in so i do not -- i do not think it was a mistake. there was a mistake made and that it was we were not ferocious in a defense. it was led by the --

governance, the state chief and the governor are in charge of the education system. emerged from school districts. in control of tay it, so i think we can get that back. have to be firmer. >> i have a modest proposal that might help. for instance, under race to the obama administration gave elighted that they about $350 million. one ates are backing out,

is the criticisms is that it waste of money. so i would like to see the secretary and the president carved out million of priorities to award states wants to drop the common core. national contest for states were not excited about the common core. the $350 million will be up among the states to offset the cost. think something like that ways actually go a long towards putting some -- this is fundamentally going to

relate to the common core difference going forward. >> i think that is a great note and down. we could give a round of applause for our panelists. those of you at home, please converse using the hastag. thank you for coming. [captions copyright national cable satellite corp. 2014] >> former washington post bradleye editor ben died this week at the age of 93. 995will show you his 1

appearance on book notes. on monday, the brookings institution hosted a forum on health care policy and accountable health care organizations. this portion is about 30 minutes.

i want to give you some big picture context. talking as mark indicated about we are in the development of a proposed rule. talk to you a bit about where that might be headed. we are about four years out of the affordable care act. we are one year out of the 50th anniversary of the medicare statute passed in congress. where are we? measures --ortant on controlling costs, this news is historically good. we are in the middle of a four-year were the cost per capita is going to be flat. some of that data is already in.

performance. that bodes well for the program in many ways. the trust fund, if you go back to 2009, the forecast is it was eight years from being exhausted. in 2017.d be exhausted this year, they are saying that we are 16 years from being exhausted. when you control health care costs, it allows not just relief for the federal deficit, but allows for battle -- better health care policy. the discussion to get rid of it is only made possible by the low cost of medicare spending. that is the cost side. on the quality improvement side come historically good news. conditions areed

dropping. ventilator assisted pneumonia. lots of improvement and care. hospital readmissions have dropped. comein five beneficiaries and 19.5% readmitted to the hospital with an 30 days. that is in a precipitous decline of 17.5%. what is causing all this good news? there are a lot of good factors. policy predating the aca and things coming out of the affordable care act. what you see at the beginning of a genuine quality improvement , welution in health care see actions by other payers, commercial payers that are incentivizing these changes.

we are in a good position. how do we continue this level of performance and department? challenges ahead are significant. -- more of a challenge is baby boomers. -- we have 20 years 50 million today. in the next 20 years, we will add another 30 million. a 60% growth in the next 20 years. a very substantial challenge. landscape we view the program and. we are in a great position of controlling costs.

. we have to continue to support delivery system performance. secretary birdwell, within her first 100 days articulated a vision, providing information to providers so they know how to improve and where they need to improve. improving the incentives, so making sure all of our payments and support improvement. and building capacity within the delivery system for improvement. and i think the aca initiated a lot of that work. if you see on the quality side, on information, we're providing quality measurement in almost every one of our provider groups in medicare, providing transparency with publishing these on our websites, whether nursing home compare, hospital compare, and more importantly, and this is where i wanted to get to, is we're injecting the notion of value of paying for quality and efficiency into all of our payment systems. and what are those payment systems? very briefly we have the

medicare advantage program, we have the fee for service program, and we have got new models of care that mark referenced. in the medicare advantage program, a lot of progress, the affordable care act set us on a course to pay more reasonably, getting significant savings there, at the same time, we're getting higher quality care and medicare advantage, 60% of medicare advantage beneficiaries next year will be in four and five star plans. premiums have been essentially flat since the passage of the affordable care act. good news there. in fee for service, hospital value based purchasing, physician value modifier, even in dialysis payments we're building in the concept of paying for quality, paying for efficiency into all these fee for service models. but as mark said, for are many providers, they believe to truly achieve change and fundamentally change the way they deliver care, they need to move out of fee for service and move into a different model. and that's where acos and other models come in. i'm not going to go into depth unless we get questions, but the innovation centers testing any number of models around acos, primary care medical homes, lots of variations.

i'll focus on acos, but as i say, it is an important part of our strategy on new payment models. so where do we stand on the aco program? early results and i would use very similar slides to what mark did, the early results are very promising. particularly on the quality side. on the quality side it is pretty clear that most of the acos have figured out how to improve care beyond what is provided in the fee for service system. and we see that in beneficiaries. one measure we do is patient satisfaction. patients in acos tend to be almost across the board more satisfied with their care than patients who are not in acos in the fee for service program. there is more quantifiable measures. the pioneers from one year to the next improved collectively on almost all objective measures of quality. i think 28 out of 33 measures they improved on.

in the shared savings program, the shared savings acos outperformed fee for service in 17 out of the 22 measures, where large group practices had reported quality measures. so on the quality story, very good, promising results. on the cost side, a little less -- more of a mixed result so far, but i would caution it is very early in the program, you recall if you went back to january 2012, there essentially was no such thing as an aco. and now we have as mark said -- i usually use the number 360 in the medicare program, but many more in the private sector as well. with 5.6 million beneficiaries participating in them. several pioneers have clearly figured out how to generate cost savings and do that consistently from year to year. a number of shared savings acos as well. but the story is still mixed and the question isn't can the leading edge figure out how to generate cost savings, but can we get the vast majority of the acos in the long run generating cost savings to go along with the quality improvement.

so if the situation is promising, but needs to do better, how do we move forward? again, i go back to the secretary's vision, we need to improve the incentives that the acos receive, improve the information and help build the capacity of the acos. since as i mentioned we're developing a new regulation for the aco program, i can't tell you specifically, but i'll talk about now briefly are some of the areas where the private sector, the acos have come to us, including through the brookings learning network, and have told us areas where they think we can improve. they map perfectly to the incentives, capacity building. on capacity building, we have heard, you know, a lot of small practices that want to get into acos or in acos need help in understanding how to transform themselves. we heard this outside the aco community. how do we help small practices in clinical transformation? and that's something the federal government is talking a lot about. we even have spoken publicly about and solicited ideas, how could the federal government support small practices in

transforming better? but specifically in the aco context, one of the things we heard is, well, since this is fee for service medicine, when we assign a beneficiary to an aco in one year, many of them are not assigned in the second year. and some have referred to that as the churn of beneficiaries. so it is harder for the aco to focus their interventions and resource investments on beneficiary if they're not certain that they're going to have that beneficiary in the long run. i think mark made reference to some of the savings opportunities are in the long run. so we have been talking to the private tv-- to many of the acos and thinking long and hard how to you get a more stable population for the acos. the challenge is this is fee for service medicare, meaning the ben fishery beneficiary is not locked into a network. and then broadly, i think, how do you get a nonchurning is part of a broader category of how do

you get more beneficiary engagement. this is true not just in the aco context, but any context where providers are trying to provide care better and in a different way. how do you get the beneficiary engaged in the care so that they're doing self-care, following medication adherence, those sorts of things. on information, we heard consistently that acos need better and more timely information from the medicare program. we have been working hard to do that. we have a ways to go. i would say, though, for the -- in cms's behalf, two years ago we essentially were sharing claims data with nobody. now we're sending monthly claims fees to over 300 acos every month on behalf of -- with data of over 5 million beneficiaries. this has been an enormous change for how cms saw its role, but i think it has been a successful one, but it has a ways to go. i think working together we can figure out better ways to share information. and then most importantly we

heard kuwait a bitquite a bit of talk about changing the payment rules for the acos. one of the things we do is we don't pay on the first dollar of shared savings because there say lot of variation year to year in medicare spending, so we create minimum saving ratios, first couple of spersepercentages. many acos balked at that, feeling like they did generate change it wasn't a statistical anomaly and would like to be paid for that. one of the things that is implicit in all the numbers mark shared on who generated cost savings is what is the formula for what is a cost savings. the shared savings program followed the statute in the affordable care act of using a national benchmark, meaning you start with the costs of your own beneficiaries historically, but trend that forward based on what happened nationally in the medicare fee for service program. couple of things to observe about that. one is it is an interesting time

to start the aco program because the fee for service program is essentially been not growing at all. so that's a very difficult benchmark to meet regardless. two, a number of acos have said i'm in a community where costs are growing much faster than the national average. it is not fair to only give me a benchmark that grows by the national average. the only thing i would say is we have been listening very closely to these, but this was the point of contention in the drafting of the affordable care act and it is very delicate regional balances that come out in those discussions. but we are hearing quite a bit about whether the benchmarking methodology is the one we should stay with. we are proposing that acos that generate savings over a number of years and continue in the program that we would do something call rebasing, which is we're using historical based period, we roll that base period forward. some acos feel like if we keep rebasing them over time, their opportunities to generate savings will be diminished. we're hearing a lot of acos asking us to not rebase or to

approach it differently. mark made reference to a lot of acos want to provide care differently in ways that aren't paid for by the medicare fee for service program. and they can do that, but they're not paid on a fee for service basis when they do that. essentially they're investing their own funds. so we have asked -- we have been asked by the aco community for a number of waivers meaning they don't want to have to follow the three-day prior hospitalization rule in medicare, they want more generous access to the home health benefit, and then finally and probably most conceptually tricky as mark said, many of them want to not be paid during the year on a fee for service basis, but would prefer to be paid on a capitated basis. that would free up the dollars for them to do a lot of innovative things. as i said, it raises some conceptual challenges which is would the acos then be like an ma plan making payments to other providers, imemploy that

therewould it imply there is a network. these are all ideas we're taking seriously and considering as we propose a new rule. we hope the new rule will be out shortly so the public can comment on it. we will go through the normal public comment period, which is -- this would be a proposed rule, we would solicit comment and adjust the rule as appropriate to public comment and hopefully have a final rule early next year. but, again, this is in conclusion this is a major part of our strategy to continue the improvement on controlling costs in medicare and improving quality. it is part of an array of strategies that range from medicare advantage all the way to our fee for service payment systems. but it is one of the keystones and one we are looking forward to working on with all of you. so with that, i will pause and take any questions. and i'm almost right on time. [applause]

>> so, while sean is getting situated, there is a microphone you can clip right on there, i'll just start with the first -- we're framing the first question. a very broad overview fitting the aco program into a wide range of payment reforms taking place in the medicare program generally and in cmi in particular. one of the things that you highlighted was basically that -- how important it is to think of acos as not just about a payment model, that there are other changes that are needed too. you talked about a lot of the regulations in medicare's payment systems on things like no requiring a three-day stay at a hospital before going to home health or post acute care facility. uses of home health services, typically limited because of the restriction, because of the fee for service nature of medicare payment. and you also talked about the

need for further steps, for smaller accountable care organizations or smaller provider groups to be able to get off the ground in these kinds of big payment reforms. and i know that more of this is going to come up in that regulation, which is coming out soon. >> soon. >> great. but you have made some other announcements recently from cms, the administration has, that pick up on some of these other issues, for example, just recently advanced payment program for rural acos. i wonder if you could talk more about that, maybe about recent announcement from the office of the inspector general, i believe, about extending program to give acos and some other providers that are participating these new kind of payment arrangements, a bit of a pass from some of the restrictions on money across providers and the like, sharing resources across providers that, again, are intended to block some challenges in fee for service that may be less of an issue in

the coordinated care approaches. maybe you could talk a little bit about how you see acos in the context of some of the other policy changes and where those might be headed as well. >> sure. and thanks for that question. and, again, just part of what i was trying to say in my remarks is acos are important and big and growing part of the program, but they're part of a broaderstrategy to improve care and reduce costs. on the specific topics you raised, we had as some of you might know created a -- at the start of the shared savings program something called the advanced payment mod toll -- model to recognize there are a lot of providers that say, i get it, i think that's the right direction for us to go in, we can do well by our patients, we can improve the quality of their care, but we see it require an up front investment, but we're just a group of small physicians or rural hospitals, we don't have the capital to do that initial investment. and so for want of that initial investment we won't be generating savings for years to

come, and improve quality. so to help some providers get over that hump, we provided what is called advanced payment, which was the -- the name was chosen carefully. what it meant was this is an advance on future shared savings that you're going to generate. we gave it to 40 some acos and said here some money to help you through the beginning to hire nurses, beef up your i.t. system so you can improve care, but when you generate shared savings you'll pay the money back to the federal government. it has been very popular. some of them did very well in the early rounds of the shared savings program but we also heard that we -- we left some groups on the outside when we designed the original one. we also heard that some shared savings acos were able to get into the program, but weren't sure they could remain in the program without some help. so we tried to design the new round of advanced payment to capture some who were in who wanted to stay in but needed some help and also rural

hospitals, i think we really didn't define it right to get rural hospitals, particular areally critical access hospitals. on the waivers you were referring to, when we created the program initially, i mean, if you can think about the shared savings program, these are often not already integrated health systems coming together these are independent practices and fqhcs coming together for a common purpose, but oftentimes when they do that, they run up against fraud and abuse laws about how much they're allowed to cooperate. the original program included some waivers from fraud and abuse laws, those waivers were due to expire this year. and the office of the inspector general has extended them for a year. i think -- i think once we come out with the new rule and show where the program might be headed, i imagine everybody will go back to the drawing board and decide do these existing waivers still fit the new program. >> it does sound look a longer term commitment to making sure

the fraud and abuse protections are appropriate for the payment systems being used. >> yes. i think you'll see continually as the program evolves, continued re-evaluation of have we tailoredthem correctly to the way the program is operating and to what providers need and what the government is comfortable. >> in the same spirit of reinforcement of the basic ideas in an accountable care payment arrangement, we're seeing in private sector are a lot of insurers putting in a number of different reforms at the same time, so not just acos with shared savings or two sided risk, but also medical home payments, bundled payments for special services and more advanced care, a number of payment reforms that all can be reinforcing. it will be challenging when medicare is trying out some of the new payment models and trying to figure out what the effect of each one is. i think what many of the private payers are finding they get more mileage by putting them all in together.

is that something that you all struggle with in terms of -- >> we do. but as you know, the innovation center is testing many different models, we have tried to allow participants to participate in multiple models. there is one statutory prohibition, which is provider cannot participate in more than one model that involves shared savings, we try to be cognizant and enforce that. but other models we think could be complementary. it does pose a challenge as you say for the proper evaluation of if you see a positive result, disentangling what contributed to that result. the one promising thing there is with the creation of the innovation center, we have much more robust evaluation of budgets than we have ever had in the past. so we'll do better, it will still be very much a challenge though to disentangle those effects. >> we'll open this up to comments to those of you in the room. we have microphones. if you put your hand up and wait

for a microphone, i'll try to get to as many people as possible. and over here, someone had their hand up first. i'll wait -- just a second. >> thank you. jerry anderson, johns hopkins university. sean, you mentioned the evaluation budget. you have a whole series of evaluations ongoing at cmmi. some programs are working. some are them are not. what are the commonalities of the programs that are actually saving money? >> first i would say -- i think i'm being rewired. i think it is too early to say. i apologize, but, youknow, innovation center's first models went up january 1st, 2012.

so, you know, to see measurable results, best case scenario would have been like this time last year. that's if they had immediate substantial impact and even then it would be limited to the pioneer acos and the partnership for patients which is a big quality improvement. but the bundled payment for care anywhere tiff initiative is getting off the ground now. some models we have early results. speaking qualitatively from what i've seen and not applying the level of rigor you tried to teach me at johns hopkins, i think what you see is it is providers who are in this mode long before the affordable care act passed, meaning providers who saw the problems with fee for service medicine, but were pursuing the right form of care, communicating well with other providers, staying close to their beneficiaries, focusing particularly on the high risk beneficiaries, long before all

of our payment systems might have caught up to that seemed to be the ones who got going right out of the gate and did well. those of whom are responding to the new incentives i do think there is a learning curve. i think -- that's why when we talk about the shared savings acos, i think you have a mix of those. you have some that are coming in saying, this is great, this is what i always wanted to do and some saying this is great, this is what i've always been doing and now i'll get rewarded for it. so i think early on you're going to see that diffusion of performance, but the hope and expectation is that the big middle will catch up. >> for those early -- those early organizations that were committed early to this kind of approach to care, it is still important, though, to be able to have a sustainable business model to do that. and do you think the shared savings program is enough to get there, is your sense from many of those that they like to do more in the way of payment reform?

>> again, i think there is a huge diversity out there. there is certainly a leading edge of acos that want to move as fast as possible to more financial risk, meaning almost capitation. though they tend to want to get away from shared savings, meaning they want to budget a perspective budget, they want capitated payments based on that budget, and they want to, you know, let the government take a couple of percent off the top as a discount and then on their way. i would say that's a small minority, but very large, sophisticated organizations. i think there is a larger group that are still feeling out what is the business model and what do they need exactly. but many of them clearly want better upside potential with less downside. >> time for another question up here on this side. >> thank you. my name is lee young.

when we are talking about the budget or whether there is care, i have a very strong concern about it based on my research about hospital utilization and based on personal observation. i just wonder if you can address issues about accountability and the record and real patient care. in writing the response is totally absurd. and then you have abuse and unnecessary -- or even mental care. they have a private patient

rights advertising they will pay by the hospital, but they are really -- if you don't address this couple issues, the whole thing is meaningless. so could you -- >> i think you're making what is a point that i should have said at the beginning, which is our focus on cost containment needs to be matched by our focus on quality improvement. i think we have tried to do that, but you're right, anytime you create a new payment -- every payment system has incentives. whether it is positive or negative, whether they move you in the right direction. but when you create payment incentives to increase efficiency, you need to have some confidence that your quality measures are making sure that efficiency doesn't come at the expense of the patient. with that i would say, you know, the results at least so far in a shared savings program are very promising. patients are happen yes, seem to be getting better care. whether it is the shared savings program or elsewhere, i think our measures of quality have a long way to go.

and i think they have come a long way, but i think there is a long way to go to make sure we're measuring things we care about and capturing -- the other tension i would say is there is attention in the shared savings program between those two would want to measure everything, meaning we don't want any possibility of something adverse is happening to this patient, versus the acos saying don't drown us in reporting and measurement, allow us to focus on things that are really mattering, that are a handful of really salient measures. and i think that tension hasn't and i think that tension has not yet been fully resolved. >> that is part of the reason you are doing so much, to try to expand the scope of measurement while reducing the burden on providers. out thatust point there are a lot of aspects of patient safety where it is very much in line with