i don't think any of office support allowing cms to use this information in this way. i know that i do not and i know that the distinguished doctor does not. cms -- and i went into it, probably way too long remarks of the long track record of missing data to deny access to new treatments. and i gave the example of the former head of the cms and bachelet coming to my office since i have a hold on him, and he actually talked to great providers and cleaned up the ladder that we sent and i felt that we had gotten along fine and then within months cms was doing precisely the opposite of what he indicated. and then later when we had the chance to visit on an airplane i let him know about that and he expressed shock and amazement. so, i think we have to take that extra step using the word prohibit. i just think we should have a flat prohibition cms shouldn't be allowed to use this information to set payments or coverage for treatment. that doesn't mean they can't in four or disseminate. to better educate and better help doctors across the country. and let me just repeat in te

cms? >> no. we're dealing with the white house policy. >> oh. >> who, in turn, deal with their agencies. could i go on to try to define a sensible center here which we just talked with your staff, but i don't think -- okay, the potential counteroffer which would say this, so the senator reports and recommendations are prohibited from being used as mandates for payment coverage or treatments. yours is prohibited from being used for payment coverage or treatment. all we want to do is after prohibited from being used, insert the word as mandates. >> i thought that was sort of the plan. i was impressed on on. >> actually, i thought it even more finely tuned what you wanted because we instructed as we were going to have this conversation, pay attention to what the others were saying. there have been bonified arguments raised. of course, the need for outcomes research is widely accepted in most circles. so i could go on and tell you what their rationale was. their mandate and explicit means of regulato

-- >> darth vader is the head of cms, that's the whole problem. >> senator roberts, cms is not in charge of the center for health outcomes research and evaluation. >> who is? >> the ahqr, the agency under the secretary charged with quality. that is where it is. and in the bill, it creates an agency within an agency there to see this. this is not at cms. >> has this outfit been -- i mean has posse been formed up, is it riding? >> the posse that's been formed up. let's say this, no, where the framework that is in existence was created during because of the stimulus package in which we vo voted for $1 billion to begin to do -- >> well, i didn't. but go ahead. >> for outcomes research and replaced it with -- we create and interagency task force and put this in ahqr. $400 million of that research is already designated to go to nih. so it's not cms and bean counts. >> but yes, wouldn't nih -- i interrupt you. >> i'm just asking you to read the bill. >> say you have this -- kounds like an acronym for water or gold, maybe. but this doing this. and we establish money to do this and part of it is

per orders of the dictate of cms. and so cms has decided that's too expensive for the benefits that we get. so now no medicare patient can have it. and we're already starting to see inside

there is been an asset at the cms cannot use it. -- there is nothing in here that says that the cms cannot use a. i love you. a levee to death. >> you are killing me. >> i love you to death. >> you are killing me. >> the where the ides of cms > -- the where we did beware the ides of cms. it is going to be a blueprint for rationing health care. maybe i'm wrong. maybe i've been there all of these experiences and think that there are things there that are not there. i do not think so. i do not see any problem if it is duplicative. where has it been said that they cannot do this? i hope people would vote for the amendment. i appreciate the comments from my friend from maryland. >> all right. no further debate on the amendment. all those in favor -- >> i would like a roll call vote. >> know. >> no by proxy. >> know. >> no by proxy. >> no by proxy. >>no. >> no by proxy. >> no. >> aye. >>aye by proxy. >> aye by proxy. >> aye by proxy. >> aye. >> aye by proxy. >> aye by proxy. . >> aye. >> no by proxy. >> thanks our colleagues. -- i thank our colleagues. >> could i inquire -- senator mikulski was

so the entity thing is a broader concept than just cms. i'm more worried about cms because i think that's where -- that's where all of this is going to happen, but -- and i said before that there's nothing in our counter counter language, if that's the way to put it that says anything about denying doctors or the health care delivery system and everybody involved in it from being informed and -- or from any government entity to disseminate this information which is very valuable information. we need this information. >> what about treatment? >> that language that says recommendations are prohibited from being used by any government entity for payment, coverage or treatment decisions. it seems to me a treatment decision involves being informed provider. if you're prohibiting that information and treatment decision you're doing exactly what you say you're not doing. >> and the sentence right after that says this does not mean we'll disseminate the information of this april. >> mr. chairman, by my observation we've now had the same debate und

finally, cms came down and recognized 24 in the bidding process. if you have 428 people involved in home health care and you recognize 24 eligible for medicare, what happened to the other 404? that is where we were. if you have an elderly person who relies on home health care and they did not know about it and was a did they are trying to cash up and that was impossible because the number was always busy and when was not someone cannot answer the question -- it was a real problem with 404 of these entities out there. they cannot get medicare out there because of the e did. i was not happy about that. about that htime, been nominated a man to be the director of cms. i thought i would take the bull by the horns and i put a hold on him. i made public. he naturally came in to see me. he was a nice fellow. he was from new mexico. he went to harvard, but you know, he could not help that. basically, we said down in visited about it. i prepared him a list of five questions that i had received primarily from doctors and primarily from hospital administrator

we all all know it's that going to cms and that cms is under tremendous pressure to cut costs and that's what's wrong with this language and bill. it's going to lead to rationing and and people getting less health and care than they get now. if i could ask one other thing, mr. chairman, i have to leave after the vote but i know our staffs have been talking about a few of my amendments, hatch 27, hatch 9 and hatch 21 as modified. my majority will consider those --. i'm ready to vote. >> i am considering those. just as i said over and over again, i don't know of anyone on this committee who's for health ration i rationing, it's used all the time and it's not offensive. we're not for health rationing, we're for driving down the costs and deliver affordable health care and by frightening people by talking about rationing does not contribute to the debate. all in favor say aye. >> ask tour a roll call. >> clerk will call the vote. >> no. >> no by proxy. >> no. >> no by proxy. >> no. >> no. >>> senator brown. >> no. >> senator casey. >> no. >> senator occasikagen. >> no, by proxy. >> senator m

this was never intended to be the case by cms and cms deserves a lot of credit for having reduced the magnitude of these distortions and a revamping of the methods under mcclelland leadership but the distortions of hospital payment remain for many private payers who are not using drg either the old system or the new updated medicare system but they are paying on the basis of per diem for discounted charges and so this for privately insured patients the incentives for hospitals are still there now physician procedures involving new technology are more profitable for physicians ban evaluation and management services. now there are two aspects of this and this is getting into a little bit of detail. the medicare fee schedule is calibrated to the big component is the officious -- decision work that physicians personally put in to the services and fielder major component is what we call the technical office of the or practice expense component basically payment for the rent, service technicians, nurses, staff and providing the service. the biggest distortions are actually on the technical

for those that have followed this, cms assumes that a piece of equipment, and maybe it's specific to imaging, is run 25 hours a week. when i asked, what's the basis of that assumption? well, we didn't have any data, so we just chose that number, presumably not to offend too many people. net pack has recently urged that that number, based on some date that that they have reviewed, be increased to 45 hours per week, just based on the patterns they see owed there in the medical care system. so really, pervasive throughout the practice expense side of the fee schedule, there's this need to invest more in gathering more data to do this more accurately. one short-term thing is that we could do what japan does. japan in its physician fee payment schedule, looks for trends in volume, and when it sees services with particularly rapid increase in the volume of services, it takes that as a signal, well, our price must be too high. we'll reduce the price and japan has very sharply reduced the prices of the complex imaging procedures, ct scans, mri's, and cat scans. now, this is the harder part.

now this was never intended to be the case by cms, and cms deserves a lot of credit for having reduced the magnitude of these distortions, in a revamp of the drg methods under mark mcclellan's leadership, but the distortions in hospital payment remain for many private payers, who are not using drg's, either the old system or the new updated medicare system, but they are paying on the basis of per diems and discouldn'ted charges. so for privately insured patients, the incentives for hospitals are still there. now, physician procedures involving new technology are more profitable for physicians than evaluation and management services. now there are two aspects to this and this is getting into a little bit of detail. the medicare fee schedule is calibrated so that a big component of it is the physician work or really the time, effort, intensity that physicians personally put into the services and the other major components is what we call the technical or the facility or the practice expense component. basically, payment for the rent, the services of technicians, nurses, office staffs, th

that we may not get to disseminate the information, but it puts a clear prohibition on the fact that cms isn't going to ration care. >> i hear your point on this. we were watching the insurance industry rationing care for a long time without a bureaucrat or insurance company steps in and tells your doctor you can't provide that benefit or procedure because we're not going to pay for it. an irony is in a sense to the extent that that will exist. you have the private bureaucrat stepping between the doctor and the patient, which i hope all of us, i but we are not in the uncharted waters in that sense. >> mr. chairman on that point, can i say i agree with you but one of the things i want to make clear when i said government entity as opposed to cms i am also talking about the va or the department of defense, or any government entity from using cer to ration healthcare so the entity thing is a broader concept than just a mess. i am more worried about cms because i think that is where, that is where all of this is going to happen. but, and i said before that there is nothing, and our counter,

now it's called cms. those acronyms are going to ring in your ears. cms. cer is going to be the holy grail by which cms grabs this comparative effective research, and if we aim right at cost-cutting only, they will determine, not you and your determine, how many mris you might have, how many x-rays you might have. all the duplicate things we know add to cost. regardless of the circumstance, mark my words, the way it is written now and the way the secretary of health and human services, a good friend of mine, kathleen sebelius has stated it, cer is going to be used -- its main purpose is going to be cost. if we do that, mr. chairman, we're headed for trouble. because that decision between you and your doctor will be taken away. i'm offering several amendments, mr. chairman, which i hope my colleagues will consider seriously and also hopefully accept. in an attempt to improve upon this bill. they'll include provisions to protect patient choice. the patient-doctor relationship. ensure that rural and low-volume hospitals are not disadvantaged by new regulation

because we are saying it, but cms is limiting payments today. limiting payments today, so if the defense against what senator and the wants to do is that we have the language to protect it, the proof is in the pudding. we don't. they have a wide range, and they are in fact rationing care at cms today as well as practicing medicine. and creating and h adjusted life value and then measuring that against what it costs, forgets one important aspect of healthcare. that individual's human life that you are applying it to. so, when you have failed three courses of treatment on recurrent leukemia and there's a drug that will give you a 30% chance of living freer for years, and they are saying you can't have it because you are not worth it, and shall not be construed does not protect american seniors, american adults and american kids from that kind of bureaucratic malfeasance. >> mr. chairman? >> mr. chairman i do think it is important to understand what this quality of life is all about. the most crass terms, what they do in england is, they say that a

i think that is clear in full all and certainly the folks at cms intend to follow the law. we are very encouraged by the opportunity to lure from what is happening in this rapidly evolving area of medical care and certainly what's happening to produce high-quality low-cost care in various parts of the country, and to help drive those best practices across the country so all americans have access to the care and i think the investment the congress made and comparative effectiveness research gives the opportunity to do that, to tashi and what strategies needed to better health outcomes and costs which are again and places in pockets around the country but not everywhere and i think the fear is somehow this will drive rationing of care. i suggest would raise quality-of-care in a very effective manner. >> let me ask another question, something i know is important to you being from a state like im, and that is we have a challenge and our state as well as other senators in their home states where we just don't have enough doctors and rural america and my sense is, you know, one r

i hope at some point, given cms, cms's role in overseeing hippa, maybe we'll have a federal agency that will have a role to come before the subcommittee as well to find out their take on what's happening. ms. horton you stated that you think the applications are deliberately confusing. i've looked through some of those and i understand what you mean. could you be a little more specific. the kinds of question that is you found difficult and confusing? >> i haven't looked at the application in four years since i first filled it out so i can't be superspecific. but i do remember them, you know, after looking at it again with my sister and brother-in-law, they both said you need to be a doctor or lawyer to figure out the application and fill it o

and then also on the last 21 through 25, we're back to -- prohibiting cms, may not use data obtainedin accordance with this section to withhold coverage, particular service treatment or a prescription drug, and i believe we've covered that and that may not be construed. then again -- >> can you offer me a way where we can give providers protection, if, in fact, the art of medicine says at this particular instance i shouldn't do what the government recommends? >> well, let's turn to the national academies to do that because you know more about the practice of medicine. i know more about the administration. >> i'm talking about in the legislation so that we can -- >> no, that's what i mean. throughout this legislation, i have turned to the national academies for advice and direction and so on to be sure that we do not interfere. i have great respect for clinicians and the tremendous responsibility that they assume and their training and their dedication. so if you are looking at how to do that, i'd like to ask them how they think it's best done, rather than in a back and forth here. >>

so it's a 4% increase over what it would be what cms says. is that a big 4%?ell, every year health spending has gone up 6 to 7% and we always took it with grace. 6, 7, oh, the "usa today" health spending rose only 6% last year, right? they use only for that so, therefore, the 4 doesn't blow me over. then how about g.d.p.? it's about 1% of g.d.p. roughly 'cause the g.d.p. is now $14 trillion and in your mind everyone relates the $1.6 trillion to that $14 trillion now. but that's wrong. you have to relate it to 10 years of g.d.p. that'll be somewhere between $150 trillion to $170 trillion so we're talking about 1% of g.d.p. so looked at it that way, not the way bob did, bob is quite legitimate, that's another story but look at the point of view as the nation you could say well, it's not that big of a deal. it's not even lost g.d.p. 'cause healthcare is part of g.d.p. it's just on spending it on something else we're spending it on healthcare for people who are now uninsured. whether that's a good deal or not depends on that other thing. if that other thing is inv

so, cms says okay we are going to do a 5% belfiore timbers sent vaunty, an additional reward payment for every hospital able to get people on the right antibiotic at the right time within those three hours of their presenting. that seems like the kind of thing we want to encourage the health care reimbursement system to do, assuming that the evidence truly supports it. i think that that qualifies as the payment decision by a government entity that would be forbidden and even more this early cms could make this very decision unless and until this organization wrote it up. if telenational organizations decided this was the smart thing to do, then it could go ahead and do it but as soon as they organization rhoda, now suddenly can't do it any longer. so, it has i think the problem of overreaching and overbred said and risk damaging a lot of what we are trying to achieve, so i don't think it is an improvement over the present language, although i understand the senator's concerns. franqui what it creates is enough discipline free-for-all for physician reimbursement. >> yes sir. first of

basically, bonuses or penalties in for per-episode efficiency and cms to me is laying the groundwork for this in the future for medicare, as they are implementing, as directed by congress, resource use reports, which basically are for information only, reports to physicians on the efficiency with which episodes of treatment that they're involved with are provided. now, there's been some criticism by some of the proponents of c capitta ted of per bundles uses. i would bundle them in two services. one is leaving of the incentives to generate more episodes of care in the hands of providers, and possibly those providers that do very well on per episode payment, having even greater incentives. i think of the other reason is probably limited policy resources. you know, we may have to choose as particularly federal governments in whether it's going to -- whether we're going to put the limited policy resources into proceeding and developing per episode bundles, or proceeding and developing with more capitation-like approaches. ok. i did label this as a accountable care organizations. which b

the ingle brooks center at brookings where he draws on his public-sector experience having led both cms and fda. of course he also brings his background as a physician and an economist to that role. mark most recently has been playing a key role in the development of the dolby girt daschle plan, and important bipartisan agreement on health care reform. markle described some of the multi-payer initiatives that he's involved in that also can serve as a model for health care reform. >> thanks, nancy. it's great to be here this morning with all of you. how are we doing on slides? coming up. okay. like i said, this is a very distinguished panel. i'm so glad people are taking time to be here and that we are seeing so much discussion around payment reform and improving health care works as part of health care reform. i am going to talk about that, as nancy mentioned, focusing on things like accountable care and multi-stakeholder approaches to doing this. that it is very refreshing to see how much and emphasis there is on getting these kinds of ideas into legislation. this is something i think

i hope that some point come a given cms-- cms's role in overseeing hipaa and perhaps we have a family to see that has a role in this to come before our subcommittee as well to find out their take on what is happening. ms. horton he stated that you think the applications are deliberately confusing and i have looked through some of those and i understand what you mean. but could be of little bit more specific to the kinds of questions that you found difficult and confusing? >> i haven't looked at the application in four years since i first buildout so i can't be soopers specific but i do remember them, you know after looking at it again with my sister and brother-in-law of the votes said he would have to be a doctor or lawyer in order to figure out the up sulfation and fill it out to 100% accuracy. >> how would each of you improve that application process because it seems to me like that is kind of the crux of the argument here, is there are things that you didn't know that or run your medical records or your loved ones medical records that they didn't know and i don't know how you ever

wellpoint, the 2009 cms board wellpoint from participating in medicare part d and medicare advantage stating they've demonstrated a longstanding persistent failure to comply with cms requirements for proper administration of medicare advantage prescription drug program. aetna and 2003, agreed to settle a class-action suit brought by physicians by paying $470 million overhauling business practices that doctors say were shortchanged patient care. amana in 2000 he managed a 14.5 million to settle federal charges of overcharging government health programs. sigma, and 20 of repaid $24.5 million to settle allegations of medicare fraud at a hospital that it owns. that is some of what insurance companies do. then you've got hospital change. many people here are familiar with. that in fact in 2000, the hospital corporation of america agreed to pay $745 million. 745 million to settle civil charges that it systematically defrauded. medicare, medicaid and other federally funded health care programs. later that year they agreed to pay criminal fines of around $95 million. finally, and 2003, hca a

. >>> women cm -- welcome b nationals park. "nats xtra" post-game show brought to you by masn. verizon fios, over 100hd fienls channels and the fastest internet. this is big. one of those relievers ron villone telling debbi taylor back in the clubhouse this was a big win for the ball club. >> to have a win after we played the last couple of nights. young starters are doing great keeping us in the game and pitching their butts off. >> what did you think of jordan zimmermann today? >> he looked pretty nasty. looked like he had command of everything and the guys pulled it out at the end. >> do you feel too the bullpen is starting to get into a good groove? >> i don't think fwheer a good groove. i think we're getting a chance to go out and have an opportunity to do the right thing -- things and make pitches and execute. it's just everybody is playing. >> does it help that you pretty much know when you're going to come in? >> it doesn't matter to me really. i hope i don't ever have to be told i'll have a role. i don't care for it. s

and also providing a reliable resources for cms or inouye governance entity to into the development and the payment decisions to perform the technical functions is very important. i also think that limitations in private bear market power will have to be addressed. thank you. [applause] >> thank you, paul. that was excellent. now we will look at the state example where they are actually doing some very interesting things. the state of minnesota and read that we have paul geraghty who will discuss these recent initiatives that he is involved in. minnesota is well known for its low-cost care and high quality of care can really serve as a model for the nation and as we work toward those goals. >> thank you, nancy. some of you who are close to the front of the room the other is a fly buzzing over the podium here and a couple of weeks ago i would have just swatted it. [laughter] but we live and learn. thank you very much, is my honor to be here representing the state of minnesota and representing blue cross/blue shield and minnesota. the discussion we are having as a nation is really not jus

while i was sad cms we started a program started on this firm primarily integrated group practices were a number of physicians integrated groups and ipa participate in a deal like this where they still not paid the for service payments by in addition to that they started reporting on a meaningful quality performance measures for the patient population and the holes that were touched by their care including preventive measures and evidence based process and outcomes and experience measures for the common chronic diseases that account for most medicare cost and medicare started tracking the overall spending for patients in these programs. the deal was the document improvement in the number of these dimensions of the important patient's quality of care and medicare saw a slowdown in the growth trend while they get back some of the savings. at this point the latest results are about all have significantly improved quality and half have been able to get cost spending down by more than two percentage points per year. that is significant adding up overtime as the savings interim get larger ins

cbo has reported that 5% of medicare beneficiaries account for 43% of overall medicare spending, and cms has noted that approximately 20% of medicare beneficiaries are with five or more chronic conditions account for 66% of program spending. could you talk a little bit about how we can focus on those medicare beneficiaries with multiple chronic diseases, and how perhaps a program like that focusing on home and better coordination can help reduce the costs? >> well, we have not only the demonstration that you are responsible for, but i think a number of projects under way looking at coordinating care, particularly for the vulnerable high-cost individuals, and certainly having an opportunity to do that in a home base, instead of a hospital based service is not only better for the patient, but may provide some enhanced cost savings. so we are eager to work with you, mr. markey, to continue to figure out better ways to not only coordinate care for individuals who suffer from various chronic diseases, and have ongoing underlying conditions, but also to make it a more patient centered system,

cms? fda? so we want to see it expanded. it's always been that they have been allowed a budget up to 5 percent of the budget of the agency. we'd like to see a line item budget and more coordination, having more of a say in everything that every policy coming out of health and human services, than they to right now. do right now. >> the phrase more money seems to back people off on issues, and i'm -- we're here to tell you that without addressing the gaps in disparities in health, it's going to cost you more money. and to anticipate that we have to plan well, invest well so that the return on our investment is saving lives, the health of our country, and ultimately having money to be able to be expended in other areas such as research. >> you want to talk about interns, does it insure says to care? do you think that the public health option is the best way to insure access? is there anything else, or if there's no public health option that can be done, some sort of carveout for low income? >> well, most of us, i think the ent

hipaa law, basically leave it up to the states and hip pa has to be enforced by the federal government, cms, right. >> that is correct. the ultimate enforcement. >> so the value of the law, depends on the enforcement of the law. >> yes, it does and there is a fine, of $100 per day, per affected individual. for noncompliance with the law. that can be levied. >> let me ask each of our ceos this question, mr. hamm, would you commit your company will never rescind another policy unless there was an intentional fraudulent misrepresentation in the application. >> i would not commit to that. >> mr. collins, would you commit to not resinned any policy unless there is an intentional fraudulent misrepresentation. >> no, sir, we follow the state laws and regulations, and, we would not spulate to that, that is not consistent with each state's laws. >> how about you, mr. sassi would you commit your company will never rescind another policy unless there was an intentional fraud or misrepresent zen station. >> i cannot commit to that, the intentional standard is note law of the land in the majority of sta

wellpointe, in 2009, cms barred wellpointe from participating in medicare part d and medicare advantage stating they have demonstrated a longstanding and persistent failure to comply with the requirements of the proper dispensation of the medicare program. aetna in 2003, they agreed to settle a class action suit brought by physicians by paying a $470 million in overhauling business practices that the doctors say have shortchanged patient care. humana in 2000 paid a fine for overcharging government. and sigma paid $24.5 million for allegations of medicare fraud. all right. that is just some of what the insurance companies are doing, and them you have private hospital chains. i think that many people here are familiar with that in fact that in 2000, the hospital corporation of america agreed to pay $745 million. $745 million to settle civil charges that it systematically defrauded medicare/medicaid and other federally-funded health care programs. later that year, hca agreed to pay criminal charges and fines of $90 million. and finally in 2003, hca agreed to pay $631 million more in civil

we have a bill that is incomplete, no final cbo scores, not technical assistance from hhs or cms and we are still headed full speed ahead. those things are absolutely mandatory. if you're going to do good legislation of that to know where you're going and certainly have to have those kind of scores and technical assistance for people who deal with these problems every day. and even though we might not agree with some of the conclusions that they made it is extremely important that we have the best ideas we can and those people who are in the best position to give them. why? what are we rushing so much? what are we trying to hide. this is a much more serious situation than that ill-conceived stimulus legislation. if we fail to do this the right way to simply shut the health reform box we will all suffer the consequences for the rest of our lives. the preliminary cbo's korea today and it is a preliminary estimate was another clear indication at this is moving in the wrong direction amid the point that it did not comply with the democrats' own plant them to keep you have asthma than 22

miller very much and our final witness is david joos, the chief executive officer of cms energy and chief executive officer of its principal subsidiary consumer energy. we welcome you sir. >> thank you mr. chairman, and thank you all azar pronouncing my name properly. i appreciate that. >> it took me one minute up here to get it right but i wanted to make sure. >> i appreciate the opportunity to address the subcommittee this afternoon. consumers energy our principal subsidiaries serves 1.8 million electric customers, 1.7 natural gas customers in the lower peninsula of michigan. at whitson just we have a unique opportunity having developed own and operate transmission assets along with distribution and generation assets for a century. consumers energy now no longer owns transmission assets. we solar system in 2002 and it is now independently operated. we therefore appreciate the difficulty in deciding the transmission and support federal backstop authority for a new interstate lines as a last resort. we also see a need for new transmission emissions to interconnect new wenge resources that

but cms says. is that big enough, 4%? every year health care has gone up six to 7% and we always took it with grace, six, seven. usa today health spending rose only 6% last year. they use only for that, so therefore for doesn't blow me over. gdp is about 1% of gdp roughly because the gdp is now 14 trillion in your mind every one relates to 1.6 trillion to 14 trillion. but that's wrong. you have to relate to ten years of gdp. that will be somewhere between 150 trillion to 170 trillion so we are talking about 1% of gdp. so, has looked at that way, not the way bob did, bob is quite legitimate, that's another story but look at the point of view from the nation you could say well it's not that it's not even lost gdp because health care is part of gdp. it's just in spending it on something else than spending it on health care for people who are now uninsured. whether that is a good deal or not depends what is the other thing. if the other thing is investment in productive capital u.k. a gross price for that. if its hamburgers o

of the annenberg center at brookings where he draws on his public sector experience having led both cms and fda and, of course, brings his background as a physician and an economist to that role. mark most recently has been playing a key role in the development of the bill baker daschle plan and an important bipartisan agreement on health care reform and he will describe some of the multi care initiatives that he's involved in that concern as a model for health-care reform. >> thank you. it is great to be here this morning with all of you. how are we doing on the slides coming up fykes okay. this is a very distinguished panel and i'm glad someone had taken time to be here and we're seeing some discussion at around payment from an improving how it works. i'm going to talk about that as nancy mentioned focusing on things like accountable care and multi stakeholder approaches to doing this. but it is very refreshing to see how much of an emphasis there is on getting these kinds of ideas into legislation. this is something that can be bipartisan. a lot of congressional staff are working har