on his impressions of president trump. mr. woodward: we asked him about the kind of power, what is power, and quoted some things comesbama said that power to the united states because of its humility and restraint. and then he said -- and it is one of those moments where he -- i hate tower is use the word -- but real power is fear. >> c-span programs are available on ourc-span.org, homepage, and by searching the video library. doctor on-demand took a part in a panel discussion on how technology can improve the health care system. the remarks were part of a symposium hosted by pepperdine university business school and management. this is about 90 minutes.

>> what an incredible morning. the insight that dr. manual provided regarding the intent, results, and the future of the affordable care act as well as integrated care and how our industry is moving to a value-based system was fascinating. equally intriguing was the description of our complex and ever-cheesy health care system

by our esteemed panel of -- ever -- i trust their years of practical experience and i trust that they have certainly confirmed the complexity of our health care system. which it isd in changing in america. i'm going to take a little bit of view on some of these which it is changing in america. comments,, consistent with complexity issues of the day, consistent with things we need to change the system to make it better, but a slight difference from a quality perspective. representlth care approximately 18% of our gdp.ry's i think it is a to say the health care as an industry is perhaps the most important part of our economy and growing fast. that was something that was confirmed with all speakers

today. because of this, we have been building health care around the , a concept that came 10 years ago of what we needed to do within a society within health care to it increase and to increaseth care, quality, to decrease costs, and improve the visit and the accessibility for our country. what we learned this morning is that we have made tremendous progress with this initiative and that the next massive shift will continue to be towards out you-based health care. getting paid for products and services on the basis of how well they achieve the triple aim. after reflecting on what we have heard today, i think you can come away with a few impressions. -- is that in this question country we have massive issues with both cost and accessibility

throughout health care. but we do not have those major issues as it relates to quality of health care in america, and that is an area where i take exception to some of the things that have been said, not only this morning, but when you watch the news or when you talk about health care in a general setting. we sometimes lose the focus of quality ofonal health care that we have in our country, and it has remained constant from a high-quality perspective. sometimes that gets to live the size and not talked about at all. the fact is america has the highest-quality health care in the world, and certainly the best technology to impact positive outcomes. we heard a lot of talk during the election campaign of our highest-quality health care in the world, and certainly the systems and comparing our systems to sweden. we heard our system compared to morocco today. andisrespect to sweden

morocco, but i have never heard a patient say i would like to get this procedure done in morocco. [laughter] never. granted, a lot of these countries that we were talking about during the election , health care coverage for all citizens, and that is great. the other thing we were talking about is that is not free. for those of you who studied business at pepperdine or anywhere else, you learn day one that everything has a cost. who had ather ninth-grade education always said nothing is free. our great system has come at a cost. is up to us to again continue to drive quality at a lower cost and making it accessible to all. always been a caring

nation, and the notion that we have allowed people to perish because they did not have ,nsurance is frankly nonsense and you heard both cedars-sinai and mayo clinic talking about a number of their procedures and their care is given at no cost at all to the patients. in fact, with the formal care act, they get paid pennies on the dollar for a number of procedures they do every day. most of our hospitals and care centers are not for profits. ofmental health, 95% community mental health centers -- and these places take care of 90% of our severely mentally ill -- are not for profits. they are charitable organizations that would never turn away a patient who has no insurance, and a lot of people who do those services are here today, and i want to thank you for what you do for our patients, and our health care

system. granted sometimes you may not get the highest-ranked hospital in the country to take care of you if you do not have insurance, but there is always a place for insurance in america -- four care in america. this is true today. i suspect it will be true when a new health care program is an announced in d.c. andver, it is also true very possible that a major procedure could bankrupt you in our system, but that an uninsured person will be taken in during a crisis, but cannot afford preventive care. this happened before the offender -- the affordable care act and it happens today. we must continue to strive toward the triple aim as an industry, and we are. another fallacy is that the large pharmaceutical companies are the primary reason for escalating health care costs. total pharmaceutical costs in health care represents about 15 percent of the total cost. even if drug inflation rates

went to 0%, it would not change the overall escalating cost of care. i am not advocating that there is nothing that can be done to the pharmaceutical industry, and examples plenty of where costs are way too high and we need to address those issues. but we cannot take any of health care one silo at a time. example oft me give you an what happens when you concentrate specifically on pharmaceutical spending. on -- spotlight is focus is on spending,

yet spending on pharmaceuticals may need to increase to achieve overall reductions in the total cost of care. when patients stay on their meds, you will see an increase on drugs spent. peopleif they see having 96% adherence rate, they will be spending more on pharmaceuticals. what you have to look at is the total cost of care. it has to reduce the higher costs. recently we did a study that determine if you are putting pharmacies inside these community mental health centers, and you are taking away the ability for them to leave the center and then go get their prescription. severely mentally ill patients will fill their prescription at least 20% of the time. pharmacyis a

integrated in a center, severely mentally ill patients take their meds 96% of the time. that is what the study from the said.l of managed care the net savings for the population for america because of a 40% reduction of hospital stay, 18 percent reduction of er visits, amount to over two $400 million in savings on the basis of 500,000 patients. i do not understand the world -- the word trillion, but i understand what $400 million and the impact to this topic -- to this population is. so that is what i want to leave you with. the fact is let's not look at silos, let's continue to work together to work for total cost of care, and let's make sure as a society and a health care industry continue to reduce

costs, increase access, and improve health. so with that, we are going to talk about technology. and the technology impact that is having on the quality of care in our system. today's panel is pretty exciting. we have heard talk about earliercine in conversations today, and last year there was an entire symposium on data and technology and the impact it is having. today we have three great panelists, and we have a moderator that comes to us as panelists last year, kathleen grave, who has that history of making sure innovation is impactful. she is one of the designers panf is currently now part of the watson program with the weather channel, revolutionizing what we do with technology. please welcome kathleen grave.

[applause] ms. grave: thank you, and what a great morning it has been so far. i am looking forward to putting this panel on board. i want to introduce you to telemedicine. what do we mean by this? what is the difference. you may hear telemedicine and telehealth used interchangeably. telemedicine includes all kinds of health care provided by communication and information technology. telemedicine is more specific to the engagement of the interaction between the provider and the patient and the medical services that are provided. it is patient-clinical care delivery highway of remote services. it can be critical, emergency

care, and it can include technical and diagnoses remotely and often for critical conditions. between the doctor and the position and the patient or a consulting team. telemedicine provides access long-distance and remotely to expertise and experts with experience in specialists that would not be available in remote areas of the world or to remote provinces. the american telemedicine association likes to give an example of telemedicine, and that is the medical peer that was provided in the monitoring of the astronauts in the early graham, and that continues today. militaryed in remote deployments to keep the troops say. it provides three areas of patient care, focused on instrumented, interconnected, and intelligence solutions. medical data and

transmission and access -- radiology, imaging -- and this gives us insight that is needed to drive the information for the patient from the details of the data. also remote monitoring of chronic care or special circumstances, so in congestive heart failure, one needs to get the regular finals of the hydration of the patient. clinical concentration is the third for convenience to allow for it to happen regularly. the use of electronic information in telecommunication technologies to support is now common and it is coming to provide long-distance clinical care of patients and education, public health, and health administration. technologies include videoconferencing, and the internet is a very common practice. it includes forward imaging,

and wirelessia, can medications. there's no end to the innovations happening around this area of health care, and we are going to see it expand fold in the next few years. insights --e data the fingertips of the providers to transform the patient experience. we had as muchve information at our fingertips to take care of the triangulation of information shared between heyer, provider, and patient. with the transformation to include telemedicine and global health solutions in patient care management, we had the increase access to improved high-performance health care systems, improve and -- improving decision-making, enabling access of all levels while reducing cost, and minimizing the patient insurance. we have the opportunity to extend patient care on the office for convenience, outultation, remote access,

in provincial and rural areas. it can be focused on patient-specific management or risk-management for populations with chronic care or problem needs. our disease, diabetes, all depending on which care management programs are created. access to a specialist is available outside the metropolitan areas so when providers graduate from college and decide to stay in cities, they can provide remote access to patients who need that in the provinces. it provides support to those doctors that are remote. it reduces travel for patients who might need frequent visits, checkups. enabling flexible learning options for a physician to consult patients, training, care management programs, bringing together a team of specialists to discuss a specific case management, to give feedback come to bring in other non-

clinical roles are experts who can contribute to that augmented information based on the environment of the patient. one common master view of the information needs experts can now contribute from all facets of their expertise. onis my privilege to bring the stage three panelists who experience asir well as their perspectives to answer some questions about the industry and its growth. there is this models and applications of telemedicine. mr. ferguson is the chief executive officer of doctors on demand with two decades of experience in mobile technologies. been a founder to be a senior executive at paypal, a high-growth committee. he has a commitment to put customers first by delivering the best possible products, a value that resonates with

doctors on demand. before joining doctors on demand, ferguson transferred pay paul into a technology-focused company, and serving as the chief product officer. prior to joining paypal, hell was vice president -- hill was vice president of a company that enabled consumers to make komen -- payments quickly. he built a vast network over 250 applications operated in 250 countries. he also worked as general manager at a company where he developed personal financial management market -- software. hea manager at yahoo,

created the finance website and drifted a friday a payment services. $1.7lped consumers manage billion in loans. hill holds a that first degree from vanderbilt. let's welcome him to the stage. [applause] mr. ferguson panelistd palace is -- came into a roll through his acquisition of one company, a city-based company. he served as ceo. the company expands access to health care in rural america. team have built his company from scratch, treating 50,000 patients across the country.

he was the president of and aure health care company that he started and led. these endeavors have grown from two employees to over 150 employees while improving and a company that he started and accs to health care and markets. to 22 health, he was the director of planning at centerpoint hospital in st. louis. new model for outpatient mental health programs across three states. prior, he began with mckinsey and company as a is a analyst, where he focused on initiatives for large organizations inside and outside of health care, and he served as the hospital -- he received a bachelor of science at the university of -- aylvania, a bad

bachelor's, at a masters of business administration, and he does not sleep. let's welcome him to the stage. our last panelist is mr. lew silverman. he has a record in health care services companies translating a passion for transforming and if it's for solutions in a successful organization. his experience and holding ,ompanies that enable quality and serve as a catalyst for industry change is at the heart of his business. committed advance care to working with hospital partners and their bedside teams to bring promise of outcomes to telemedicine services to the

patients we serve. prior to joining advanced icu care, his experience with innovative health companies informed advanced icu care. pursuing a strategy of building organizations designed to deliver success and investing in reinvesting in its clients, staff, and infrastructure to ensure continued innovation and on going sector leadership. at priors tenure companies, is companies were named to the "forbes" magazine list of best small companies for a total of 15 consecutive years. silverman serves on the board of directors on a variety of companies, public and private. he earned his mba from harvard b.a. from amherst

college. that's welcome him to the stage as well. -- let's welcome him to the stage as well. [applause] we will get started with a bit of a round of introductions and perspective from each of our panelists. ferguson: we can connect you to a ward-certified physician in 49 states, soon-to-be 50, as soon as arkansas passes some legislation here momentarily. we started out in the direct consumer market in 2014 launching our first product as a solution for lack of access to urgent care. it grew really quickly and quickly started to work more partnerships with large insurance companies like united

health care and humana as well whoelf-in short employers offer doctors on demand as a part of their health care design. this has fueled our growth, and we've gotten into dental health. a team ofilt psychologists and psychologists -- psychiatrists who work with primary care physicians to help provide a suite a solutions for consumers who are seeking on the direct market and as are part of a benefit that may be offered by their employer or health plan. we are excited about the future of telemedicine. it is an incredibly exciting tailwind for everyone in this room. everyone plays a role and can benefit from it. unlike my previous industries, it is not a winner take all marketplace. there are applications for providers, payers, consumers, and there are so many solutions out there that are focusing on

specific cases that are driving innovation that is going to lead to brand-new designs for health plans as well as changing the way consumers think about becoming consumers and this marketplace. i'm happy to be here and look forward to this conversation. >> good afternoon. thank you again for inviting us to share some of our experiences with you. now six years in the making, focused on schemes we have seen from the cedars and mayo clinic, leaders that we heard earlier today. our focus is on innovating for the mental health population. we are the nation's largest outpatient psychiatry provider, and we have a team of about 200 psychiatrists who work for us, and we partnered with them using a system so that those

physicians who can treat patients who are otherwise not able to access care. we found patients are seeking services that primary care clinics, and a lot of the safety nets settings we have talked about earlier today, but these settings do not have access to psychiatry. our providers can treat these patients using our platform. we have treated 50,000 patients to date. it differs in of that were not able to see a psychiatrist practicing our own. one story i hope can share is the importance of eating the business model right. we heard a lot of talk from zeke, john throughout this conference, and indignation is not as easy as having an idea. the other care managers involved care so you can build something that works for everybody. we have spent six years trying

to get that right and we do not have a perfect yet. we are well on our well to have expanded access to psychiatry, and we are hopeful we can share some of our lessons with you today. a tech-enabled services company. we are a mouthful. by 7 by 365n a 24 basis, providing remote monitoring of intensive care units and patience in those units around this countries. at thisn 24 states time, north of 65 hospitals. we're in the process of celebrating a company milestone. we just wired our 1000th bed, 55, --see well north of 55,000, 65,000 patients at this time. in terms of some of the themes we have talked about so far

today, we are living through all of those. model is almost perfect, but not quite. we are getting there. our outcomes are very strong. some of the headlines that we typically lead with our mortality rates reduced somewhere between 30% and 40% per icu with our involvement. when you talk about good outcomes, people walking out of the hospital, that were not planning on doing that, that is a pretty good outcome. length of stay is reduced from 25% to 30%, which has good in the visual and economic outcomes for all stakeholders in the process. we deliver our service through a number of care centers, now 8 across three countries and six time zones. we have all of our physicians are u.s. board certified.

on, 24, 7, byays 365. our workflow continues to be refined. our acute awareness of the fact that we are dealing with multiple constituencies, dealing with our own physicians who are hired in multiple citizens -- patients, families, hospitals. we are not alone, but we have inherited a very complex mix of business objectives, and we are executing really well across all of those objectives. that is a quick summary of our company. we know telemedicine is growing. it is currently a $20 billion market opportunity every year. and yet only 1% of all are accessing

telemedicine country. when you knew you had a good idea and you needed to move it into a business model, how did you get started? each one of you, if you could address that, that would be great. mr. malik: we saw the patients who needed services, but we cannot treat patients without physicians, so physicians were the second stakeholder. because we chose to treat patients in a clinical center, the payer, who is going to pay services is the fourth. without considering the interests of stakeholders, each of which is a link in the store, the model would not have grown the right way. when we think about patients, what are the services they need the most, had we make sure the providers are high-quality to create the right engagement, and

what we see the average haitian comes back to our physicians on our platform for treatment for about 12 visits over than more than a year. we have demonstrated stickiness there. how do you compensate doctors in a way that makes this worthwhile? doctors are already stretched so thin and the supply providers is far short of where demand is. coming up with the right compensation models, being able to reward doctors and offer them the flexible as you work hours they want, shifts they want, and from where they want, whether homework clinic, is also important. when comes to the clinics and the payers, we have to focus on reimbursement, and that is often something left out of the conversation on innovation in health care. and you find a pathway to reimbursement? without it, the services you provide only have a shelf life of sustainability. grant funding can only take you

so far. our focus on the medicaid population is driven by the treaty of the needs, but also by the fact that 48 medicare programs allow us to expand at a pretty aggressive space. mr. silverman: i have been with my company for three years, and my moment came when i was tried to figure out whether i was interested in interviewing for the ceo position. ofing been through a number innovative events in health care including the early stages of revolution, which some people think is a good thing and it wasnot so much, fairly simple and straightforward. i mention things that were discoverable as part of my diligence. when you see a nascent service

that is reducing mortality rates, length of stay significantly, doing that in a way that has a good economic outcome, somewhere between -- easy for met became to see this had legs and that it was a pretty interesting opportunity to jump on. was early days, as it was for all of us in telemedicine, tele-health. to try to keep things nice sensible, you have great roi ins with a tangible an area where at least in our area we are dealing with a severe shortage of trained intensivists, being able to deliver those outcomes with a positive roi, it did not take long to do the diligence. mr. ferguson: our story is

civil. everybody manages their daily lives on their mobile phones. -- bank our bannock balances. we order food to be delivered to our homes. why do we pick up the phone, call the doctor and schedule an appointment for next week, drive, park, weight, -- wait, wait a little bit more, and then see a doctor for about two minutes. why do we do that? that was the founding principle for doctors on demand, let's solve that problem. we started with a simple service that could diagnose and treat 18 of the top 20 reasons why people ices. to doctors' off these are relatively easy things to treat. will able to find a corporate of consumers who lack access or just value the convenience. twobase is bifurcated among

different types of consumers. one, folks who live in more urban-populated areas, who live and die by their mobile phone and they do everything on their friend -- phone, and they are looking for convenience as a natural way for them to get care. and then there is another segment which consists of people who live in areas where access to care is a real problem. and one of the things i do every day is i read all of our customer testimonials that people put out, and it is a source of inspiration, but also good feedback on how people perceive us and what types of problems we are solving with our solution. i cannot tell you how many times i read thank you so much for your service. i used to have to drive to the five miles each way to see a doctor. we are focused on access and convenience as the two main drivers. ms. grave: access and convenience is important. we see it is a reallocation of

the same resources. doctors that we are very much in need for, supplied a short and demand is high. are you saying there are the potential for new roles in the model of delivering telemedicine? mr. ferguson: we started out with contracting on an individual basis with doctors to find short blocks of their time where they could experiment with telemedicine. as we build up volume, we started hiring physicians full-time. one of the reasons we have been successful is we have differentiated on that principle. he tried to build a national practice across the board that care about our brand, that know that patient experience is critical, and more and more people request appointments with those individual doctors. about 30% of our visits today are appointments selected from

consumers who want to see a specific doctor that they have had an interaction with. the way we support that is by doing multistate licensure for these providers, so as they come on the platform and demonstrate their ability to create a good connection with the patient and deliver good care, we license them in more states so they can have a larger pool of consumers to become patients with. and so that is an interesting evolution of how people think about practicing medicine. , if you seek about a typical primary for brighter in in sanncisco -- provider francisco, they see patients everyday, can be from several hours a week to get to a downtown location, and live in an expensive part of the country. live inave people who little rock, arkansas, -- that is a bad example.

cost of livinger who can practice their craft with all the b.s. and three patients who live in san francisco. it is an interesting phenomenon of not just shifting the cost of but mechanisms for optimizing their time. so we are able to allow physicians to work from home and see the same number of patients, earn the same level of income, and not have to be restricted to working in one geography of the country. mr. silverman: in our case, building on the prior points, we are delivering expertise broadly. sourcing it in a few markets and delivering that expertise to many markets. for perspective, we have our own staff, our own mso.

we will license typically -- they are licensed in north of 20 states. we do that ourselves. we will credential them in many hospitals, and that is so that we can solve that access problem and the shortage of staff problem that many hospitals face. supply, of accessing one of the things that is interesting about our model is that we contract directly with physiciansl, and for that join us, they are for the first time in a long time able to focus exclusively on providing care to patients. they are not involved in any collections,ng, they come in, they log into our establish their connectivity with a hospital

they are assigned to, and they are practicing medicine for the entirety of their ship, and then they go home. for the people who are chasing paperwork, bureaucracy, chasing after payments, and asking questions, it is a pretty good gig. those are a couple of other aspects to consider in your question. in addition to lou's point, and in addition to lou's point about intrastate licensure, to get more doctors to improved lou's liquidity of , there are a few other ways telemedicine can help move the needle on supply, and it is not to say he can fill the hole deficit gap. but on the edge it can make a difference.

one thing we are seeing is many of the providers who work for us are choosing to use telemedicine in addition to their regular full-time job. one thing we are seeing isyou'ra making week provider and them a 45 hour week provider. working sodel is that our specialists, psychiatrists, can support primary care providers to deliver more behavioral health to the primary care channel. when the psychiatrist is in a primary care physician's office, we're helping that primary care provider management will health better. unless you can find a way to grow a doctor tree or in nurse practitioner tree, you will not solve the supply issue, but we can try to expand the box we are in. ms. grave: thank you. we have heard videoconferencing, cell phones,. what do you think might be the next disruption of technology to

help support telemedicine? is there any news on sensors or other technology that may be helping the process? wave of innovation happening on the hardware side where more and more you're able competing power into small devices, some of them in your home -- phone. the cameras in your phone are so powerful today that you can hold them up to your throat and the doctor can have an image of your tonsils as good as in person. in some cases better because of the light from the camera. and so i think we will see in the next few years the cost coming down to low enough levels where the average household can stethoscope, ad blood pressure cuff, a scale -- that canyour

feed them into a health record that your physician can read and monitor, and if we can develop models of care that are far more preventative and corrective that that data.e without that is one area where i bet my life will happen in the next five years or so. there are frontier technologies we like to talk about. artificial intelligence, virtual reality. the truth is those technologies are so far out right now is that the applications, most of the business models, and not be distilled. i do not think any of us can become buoyant enough to know how those are going to impact health care. we can assume something positive will come of it, as innovators get their hands on the applications of technology. however, i would not also suggest that technology on its own is a panacea. on thes so much work table right now around care model design. if the three of us can get our

business model perfect, we can have a tremendous impact on the health care spaces we scale without creating any meaningfully new technologies. there is a lot of room to her run before we thinking about things like artificial intelligence or things like that. from our perspective, we are conscious of the fact that there might be some big bank innovations out there. we are practicing on a day-to-day basis, relentless incrementalism. we are constantly trying to add features and functionalities some of our soft where that informs and supervise the work we are doing, day to day with patients that need our help. we had a fairly active and robust development team that works in our shop, and they work and in hand in a way with our clinical staff where we have the

perfect lab for figuring out what needs to improve, and we can test things quickly, innovate rapidly, and put things into production in a rapid fashion. we are also reliant on third-party technologies. for perspective, when we say we want to wire a room, we have audio-video connection to me -- connectivity with a camera in the room. on that, the camera can read the fine print on an iv bag. we have connectivity with the hospital information systems, emr, and all the bedside equipment that comes in. we are working with just about inpatient emr system that exists in the country. we are working with them simultaneously, concurrently, and seamlessly. continuing to

leave all and approve our ability to accept all that data and efficiently process it, but our perspective is on incremental improvements and we are leading the way in that area. maybe there will be a big bang in our work, but now we are busy enough with the incremental stuff. ms. grave: now if we talk about cost. where does the cost fall for all this change happening? providers,g payors, is there a reduction of cost for the care? can you give us some insight? mr. ferguson: the beneficiaries of cost savings are the consumer and the payer. so a typical cost for our country -- customers is half of what they would pay if they went to a walgreens or cvs clinic and about 30% of what they would pay if they went into an urgent care clinic, and is cheaper than

going to an er. that is for people who may have coverage or maybe they do not. many of the co-pays now with landselectable health will cost you 150 bucks to see a doctor. that is a big area that we see cost savings directed to the consumer. it is theer side, same principle in motion. if i can get my employee to use doctors on demand instead of going to an urgent care clinic or an er, as the payer i will save anywhere from $100 to $1000. it is a very strong cost savings, but also on the employer side, it is an absenteeism in play. a lot of our customers are employing hourly wage workers who work at restaurants and other places, and if they can

enable them to do a video visit on the job or in their car and it can prevent them from being off shipped for three hours, it is a big deal for them in continuing their operations and keeping a healthier, happier workforce. mr. silverman: i think cost savings occurs in two places. one is at the provider system level and the second is on the payer side of things. directly we contact with hospitals. they are in underserved care settings. there are turned into working with us is paying a significant premium to attract physicians. that could either be through a local organization, a staffing body, or through in paying a premium to relocate a doctor to an undesirable place to live. our doctors are living where they want to live. we can arbitrage that delta and get clinics accessed at the cost

basis that they were located. that is one. and on the payer side of things, where the real impact is we are are seeing ise the patience to see one of our positions that physicians use emergency rooms about 50% less, and in-patient utilization is down. thispatient's -- care,patient's downstream and so there is cost savings on that side, because that outweighs what we are doing on the provider supply side. were inerman: we discussions with a large national hospital system that will go unnamed in this session. and we were trying to get in the door, and they made a deal with us. they said we will give you our worst hospital, which is telling

you it is our worst hospital. the deal we cut back is we will work on the hospital, but you will tell us what we did because we do not want it to be any does with the numbers. they came that and said they cannot believe it, we generated a 9x return. a whole number of inputs as you might imagine, i share that as one aspect. would pointece i out is one of the really heartening things will seem particularly over the last nine to 12 months is increasingly our clients are featuring our relationship in their recruitment ads. and we have had to the point some of the things i have the privilege of reading, i see nurses and physicians day i was it not have joined -- say i

staffnot have joined the , and that is powerful. it is a hidden benefit and maybe under calculated benefit in terms of helping reduce turnover at the bedside. a couple of little anecdotes. ms. grave: we see the triangulation of provider and patient is working offer telemedicine. you have experienced and shared your approach to it and also we are going to look at what can you offer in terms of relative relation -- regulation, what appen for the adoption to take place? >> i think reimbursement is probably the biggest one. mr. malik: the regulatory framework as it exists today is

somewhere tenable. we have functioning business cause you can operate in this paradigm. it is probably an indicator of changes needed on the interstate license paradigm. we are spending a good deal to get doctors new licenses in multiple states and i am sure you two are as well and if there could be a regulatory shift that allows providers to treat patients across state lines with a bit more liquidity and less application, that the be a big isne but i say that secondary to reimbursement. reimbursement is king. ms. grave: one thing that is very interesting is it looked like telemedicine is integrating into the existing infrastructure that we know disruption is on the way, decentralization.

do you see your ability to impact that change or do you see a need to impact any change? >> i would like to think we are impacting the change by showing the industry what is possible. forbody once said you need good care is a patient and the doctor. we are trying to make it easy and simple for both the parties. ce every doctor's office has world-class technology that enables them to follow up their patient, replace the waiting room with a video visit, have their retail establishment for when it is necessary, our job is done and we would have shown the way. i think it will take a long time and there is a real need to have solutions like ours out of there for people who do not have doctors. half the population does not have a primary care physician. it will be a long world to get

there, but the formulas are showing themselves and to the proof is out there that better technology can solve problems for consumers, patients, doctors and payers. >> i would add that one of the we arewe learned and very you agnostic in a way, there's a tendency to simplify a lot of what we do in a the outside world and to think of all we do as we are recruiting them with, putting technology and telling them have at it. one of the things we have learned is there is a a whole client service ecosystem that is really important to keep the integrity of the clinic service working and whether that is from an i.t. perspective or customer

servers, desktops to him or service perspective, having that -- customer service perspective, having that hidden is important of allowing telemedicine to continue to march forward. you can have the best doctors on -- ondes and technology earth andes and technology but if you get some of these elements wrong, it is hard to recover. foot in the future and a foot in the present and it is a obviousness of delivering an important service back to buy some very traditional customer service -- backed by by some very traditional customer service. >> two comments on tele-servers. disruption is the prospect of taking got incumbent and

replacing with the new -- out the incumbent and replaced with the new. others in the telemedicine space are those innovators. the disruption works as a tailwind to us. the other piece which i think is fundamentally interesting about the telemedicine space in general is the businesses built by definition much more nimble and flexible than the businesses that are the incumbents. we do not have walls. we do not have state licensure's. burdens thate the 4-wall hospital has. as payers create news incentives -- new incentives, we have the flexibility to reorient where they care those. we can skate where the puck is going. we are not locked in with a deep

roots. -- with deep roots. ms. grave: is there any future you see where that would be a common platform or user approach to make it easy for the patients to be working with each of you and feel like there's a common approach that they would understand how to use the technology and adopted, specifically if it is needed generationally for a different demographic? is aboutk a lot of it getting the middle layer right. think about payments, for example. you can pay with a bank card, mastercard or cash. because you have this middle layer of payment processing correct, that transactional layer, what you are using as an endpoint is secular to that. at least for our business, getting to that middle layer toht, like hill said, access

high-quality technology and payer systems that are more uniform or at least workable in their application or approaches. getting that middle layer right leads us to where we can compete on the things we want to the pete and night if we can rub -- we want to compete and not rub elbows. >> the fundamental thing that the industry got right really early is respecting that your money is your money. you have unfettered access to it and building technology that enables that in the form of .echnology, atm machines this industry have to respect that the data belongs to the consumer or the patient. until it does, it does not matter how much technology unless those things are respected, it will never be

fully controlled by the consumer. >> in our case, we are clinical to clinical or business to business or hospital to hospital. although, if julie faulkner was here, she will say there's a world where there is one emr. i do not know if we will get there. we are content to use the complexity of the current environment to our advantage. that comeement through help us a little bit but do not actually change our current equation. we are going to deliver care the same way and we are not patient facing, it is a financial relationship with the patient. our relations are with the hospitals. -- you do not need one emr. let's say the exchanges are an

exciting start where you can go and see how has this patient been treated in the state? that is some sign of hope. >> imagine if you bought a car is with that car came the ability to only drive on certain roads. that is how working with us in the health care spaces right now. in a universe where you have a car you can drive on any road, that is where we needed to go. where you have the tools, we are the tools and you have the infrastructure. -- we are the tools and you have the infrastructure as long as you buy a car you can drive on any highway. ms. grave: excellent. while we are waiting for that one system, we will open up for questions. i do not see it happening either. [indiscernible]

>> a great question. one of the things the industry has done really well is legislated to help make sure it happens. having a lot of pride in what we believe to be one of the most secure health information data architectures and systems out there, to my knowledge, i think we're the only one in our competitive states -- space to have a high stress rating. and it is a constant ballo. -- posted battle. the hipper -- and it is a constant battle. -- the hip a standards are very paa standards are very strict. we know people who have been victimized i some of the goofs . it is disastrous. it starts with having a cometrained professional

from health care, they will come from some internet security background at your company and made sure your policies and procedures and technology being used as a internal process that we do day to day as most of the breaches come from the workers not really knowing what they are doing and being completely unaware of what types of cyber attacks are out there for having a really good chief security information officer is a must-have. >> thank you. regulation and i wanted to go a little bit further on regulation and compliance. there are certain state and programs which mandate the network capacity to the provider and how do you manage that

alsoical benchmark and there are some ratios, for every 5 patients, there should be 2 nurses. how do you manage those benchmarks and work with those advocacy groups? would wearification, are working with the hospital, we are typically collaborating with a bedside team and we are not replacing. that is a very important point. we are essentially added this to whatever -- added to whatever ratios they are working with so the responsibility for the ratio rests with the hospitals and those are typically bad side ratios. we are complementary to whatever that ride they -- bedside they choose to employ.

>> [indiscernible] >> for those who couldn't hear. the question was, have you seen any characteristic that make for a good telemedicine provider? that was the first question. over the six years we have been doing this, what we have come to under and is a -- come to understand is a good doctor will make the technology go away. we can train the doctor on the difference between what it takes to treat a patient in person and the deficit -- the difference between telemedicine.

we have now running too many doctors can not quite make that leap. if we are starting with a c- to make him to an a student, that is a big bridge to gap. perspective, a good doctor starts with a good doctor and that will translate well into the telemedicine space. , ifrom our perspective agree, a good doctor is a really good start in terms of the employment equation. in our model, our physicians who are working tele, have to alternate between being the out in theerest -- alpah situation and being the consultant. what we have learned to your point in question is we need to not only higher good doctors, but also hire folks who

understand and are comfortable with toggling between the two different roles. facilitate between those roles is really important to get the patient outcomes we need and the client satisfaction required for a good, long-term relationship. that is one we have had institutionally for a while. >> in the development of your companies, how have you addressed patient diversity in terms of cultural? and sensitivity to be able to take care of the broader population? that weis something work on every day because we are serving primarily the medicaid population in our business, we are dealing with the whole host cultures.

in texas, we have the rio grande situation where a lot of patients are mexican-american and may not know english. we deal with that and minority populations, first generation working on establishing themselves in this country. one of the nice things about telemedicine is it allows doctors to be liquid. imagine, you have a position in houston spanish and understands latin american heritage and is relatable in that way. but is spending five hours a week treating spanish speaking patients and 35 hours treating not. too bad but to take their provider and reallocate that specific -- to be able to take that provided air we allocate is a social benefit and one that the be monetized. for us, a matching equation, can

we provide the provider unique to fit that specific community? >> to add with that. also, the thing we focus on is keeping prices as low as possible. i think that is the most important thing we can do from an axis standpoint to make sure our services are not only more convenient but cheaper, more affordable. sometimes it works against us, there is a price value connection that people make consciously where i personally do not want discounted sushi when i go to the restaurant. i think the same is true for some people in health care. for a large port -- part of the population, saving and asked her $20, $30 -- saving an extra $20, $30 is meaningful and it does in

lots for a lot of people. >> to add to one piece of that. one thing we find ourselves doing not as frequently in the icu setting is having our touching a very serious issues with some of the family members at the bedside making difficult decisions about end-of-life and counseling on how to make those decisions. specificndependent of cultural norms or whatever, and being able to spend at the time non-frenzied way to walk people what the choices are and represent and allow them the time of dignity to make the decisions for themselves instead of feeling like things have dictated has been a really

important and value added aspect service. that is one other addition. ms. grave: when i shared with a group of people i would be doing with this panel one said it's the timeliness of the information that can be delivered if i am having a trauma and need that to the , itor around tele psychiatry cannot call in and wait a few days. it does not help. and the same as end of life, these are critical moments that come up with you cannot anticipate them. that was an important piece of it. care,you think of health the ongoing argument, you cannot always value the intrinsic value of the patient outcome and their joy for life and well-being based on a lot a what you delivered to your platform. any other questions? >> this is more for hill and

samir. i mostly work with seniors and as beinglikely seen that the tell and of adoption of technology but i see seniors with transportation issues and potentially ideal clients for you. i have seen firsthand how underserved seniors are in it comes to mental health act as. -- access. how do you work with seniors to help them overcome trust or technology barriers to utilize your services? >> that really is a great question. startedback to where we of getting the business model this speech to the patient engagement side. the way we have approached the senior population is to piggyback on those folks with already established the right

trust relationship with the seniors. we will work with skilled nursing facilities. it will be the folks at those who are promoting tele psychiatry to the elderly population they are serving. that is a vastly different proposition if i am knocking on somebody's door and it takes them 30 seconds to come to the door because they do not know me. they are used to certain things in terms of where they can get care, who tells them what good care is. for us, we are trying to plug into the existing framework, whatever they may be and have those folks promote our services to the senior population. users are5% of our actually over 50 years of age for it tapers off quite a bit after 70's. for the 60-70 population, you

would be surprised how tech savvy a lot of folks are. my mom is 73 and lives in a small town, whenever whenever new product, i will go to my mom and say, can you use this? what do you think? anytime you are developing a ,oftware solution or product ease of use is the most important thing you can focus on a. making sure your software is reliable and designed in a way that is really simple to use is the most important thing you can do for accessibility for everyone. >> if you get that right, you can leapfrog the problem. the ipad is a great example. the bald babies and --ogenarians very readily usain bolt babies and octogenarians very readily -- you see babies and octogenarians very readily using it. >> hi.

children's there were pre-clinic -- fair repeat clinic -- therapy clinic. is goingt sure if it to suit our client population. i wanted to know if you had any comments on this particular client and whether you have noticed any success in the industry? thank you. we have really little experience in a segment. we have interest. so far, we have not found some arctic technology to help us -- found supporting technology to help us address. could make the case that you solve the problem that is much, much more complicated. you are getting patients in icu

with their inability to make decisions to adopt a technology like that. that seems a far more complicated problem. with a working with the people on the ground with those patients. the occupational therapist am a physical therapist, -- physical therapist, what will work on that population, that is our business model. we will hear you out on what types of modes of care will be most effective, what are the characteristics you think will be effective. we can back sell that for you. you know your population better than we do. area,don't work in this but i do think there are plenty of companies that produce white label software to enable a provider, such as you, to have a meaningful, remote sessions with your patience.

especially with the technology that exists in your field with microphones and everything, in some cases, you can do a better job with some of the technology. >> [indiscernible] it looks like some leaving edge of a future movement such as health insurance being sold across state lines as well. the question that comes back to me is what you do in terms of managing quality? and might be more for hill samir, which is it you guys are in patient care.

how is the quality piece of it and whatr regulated you do about that in terms of measuring the outcomes? how exactly do you measure them? our answers are going to be different which hopefully gives the audience more to chew on. our providers join the existing care team supporting that patient. a patient is part of a community careh center and that has centers, documentation requirements, protocol. the provider we are breaking to the table is reference check and quality tested as a basic provider from our side of the table. as soon as the provider becomes part of the existing team for the patient, it gets the provider on the existing quality standards. when we are talking to our clinics, the paradigm we use them it should be as if the

provider was there in person. anything you are doing to a provider on site, hold our doctors to the same standard. we do a few: things. but, the first thing we do is ask every patient after their video visit to rate us on a scale of one to five. that in and of itself is relatively novel in the industry where you can immediately provide feedback to provider about their interaction. we have a 4.8 average. it is something our doctors love. at the end, they get to read and get instant feedback as to how it went. for those of you thinking, that is great, but patients do not always know what's is quality and what is not. we have tempers and of our physicians times doing

peer-reviewed on other doctors -- we have 10% of our physicians' time doing peer-reviewed on other doctors. we have a whole host of other metrics from antibiotic prescription rates, tracking below industry average. and other initiatives that our chief medical officer is passionate about that we drive. our practice being virtual and technology driven is the amount of data that we consume and analyze and report back and one of the single sources of delight and satisfaction that we measure for our providers to make sure they are happy and productive and they love getting the data. they love seeing how they are tracking versus other doctors in the practice, just getting real-time feedback loop has been er in -- huge driv

outcomes. suggest you want to may each have a t-shirt and if you have any saying to put on, we would love to have your input. lou is holding onto a good one right here. [laughter] lou, would you like to go first? they areow the shirts, british or something, the queen, what does it say? keep calm and carry on? don't worry, health care is getting better would be a nice things to help people understand the perspective. in fits and spurts but we are moving to try to make things better.

ethat effort is all going to result in better -- a better health care system in this century. similar to help is on the way. this industry attracted me because of its relative level of immaturity with technology and adoption and attracting a ton of to bringrepreneurs fresh perspective on how to build services and experiences that will help drive up quality, drive of accessibility. there is so much excitement and innovation going on that we may not benefit but certainly our children will. that keeps me going. >> so, a little plug here. if you have not read the book by founder, aike fabulous story with a lot of behind the scenes stuff you

never imagined would be part of the nike history. in that story, in that book, he tells a story about one of his teachers talking about the history of the oregon trail and the exploration of the oregon trail. one of theted slogans as part of his mantra and that mantra became first the subject of my annual year into letter to my team and will closes out today. the t-shirt, if were going to put it on a t-shirt, talks about the adventure we are on in telemedicine. the teacher would say "the cowards never started and the weak died along the way and that leaves us." ms. grave: thank you very much. thank you, gentlemen. [applause]

>> i think we have some awards. yep. thank you very much. hill, thank you for today. >> thank you. [laughter] >> samir. [laughter] >> what did you suggest? vip. you are all very important to us. thank you very much. [applause] announcer: a symposium exploring

educational opportunities and integration in the u.s. cents brown v. board of education -- it declares state laws establishing separate public schools for black and white students to be unconstitutional. the thurgood marshall fund will host the symposium this afternoon at 1:15 p.m. eastern and we will have it for you on c-span. tonight, conservative economists will discuss the impact of government programs on the poor. stephen moore ban took part in talked about social security. it turns out we round some the numbers with my friend, which we round these with a actuaries of the sick social security -- social security administration. instead of the tax taken from the paycheck, what if we just said 10% of a workers paycheck will go into an ira account?

then they own it and accumulate the interest over 45 years that they work. what we found is if you did that compared to social security, assuming an average rate of return, the average poor person would not only get a higher benefit from having to this individual account but they would be able to leave $1 million for their kids. social security, let's cut to the chase, social security has robbed every low income family of $1 million. that is not something you will hear a lot, but it happens to be true. announcer: you can see the entire discussion of the impact of government programs on the poor tonight here on c-span. >> on sunday, author and journalist will be our guest. up looking at thousands and thousands of faces onto lucy the one face you feel

like it's put on earth just for you and you fall in love in that trump was like that but the opposite. when i first saw him on the campaign trail i thought this is a person who is unique, horrible and amazing, terrible characteristics were put on earth specifically for me to appreciate or on appreciate a whatever the verb this -- unap or whatever the verb is. i had been spending the last 10 or 12 years prepare for donald trump to happen. aibbi is the author of several books including "the great derangement."

and his most recent book "insane clown president: dispatches from the 2016 circuits." we will take your calls, to and facebook question -- tweets and facebook questions. th" live from noon to 3 p.m. on sunday. >> president rousseff out several tweets earlier, he writes about the russian investigation, russian officials -- president trump sent out several tweets earlier, he writes about the russian investigation -- the top democrat investigating responds, saying -- the congressional intelligence committee has requested information for president trump's personal attorney.

nbc news reporting the same request sent to former campaign staff and aids. this morning, washington journal talked with reporter about the week ahead. -- the former campaign staff and aides. >> the politics editor of the washington examiner talking about the week ahead for the trump administration as of the work week begins after the long holiday weekend. the president has tweeted that it will come this week, his decision on the paris climate climate deal. explain where we are on that reports from over the holiday weekend that the president was leaning towards pulling out of the paris climate deal. guest: it would be much more consistent with what the president ran on. a lot of his constituency is people who -- their industries have been affected by environmental regulations. the president has not been a very big supporter of international agreements of this kind in general.