we're going to turn now to joe newhouse. joe it's often asserted that the u.s. is an outlier in spending. how big of an outlier are we if we are? >> thanks, susan. this discussion somewhat reminds me of that movie. not many of you have seen it. its a classic -- it's a classic japanese movie and basically presents four different views of the same reality. and i think that's an example of what we're hearing here. i noticed in the green book that you were handed when you walked in there's the usual slide which i'm not going to show you on page 7 of the u.s. spends a lot more than everybody else which susan alluded to. what's less well appreciated although ken mentioned it in passing and my first -- on my first slide is that -- how do i advance the slides? the -- what i have done here is look at annual growth rates per person in real health care spending over time. so this is almost 50 years. and the asterisks -- these are the g-7. by germany, italy and japan because there are strange things about the numbers. not just they're different. germany had reunification in

we heard from joe newhouse that the problem of rising growth in health spending, those growth rates is really a problem that is ubiquitous across the world, and that notwithstanding the fact that the u.s. has a higher level, the real issue than the other countries t real issue is this rate of growth or cost. how, as he mentioned, nothing grows to the sky. joe, i was reminded of the things that cannot go on forever will stop. and you mentioned that we are probably going to halt this dramatic rates of growth in health spending. you don't know exactly how, we'd love to hear you perhaps address if we near the midst of that stopping now with consumer directed health plans and high deductible health plans and people not being able to afford care and all the other factors currently. we heard from jim fasules about the beneficial aspects of a lot of the technology that we have adopted. with respect to cardiovascular disease, particularly as evident in the 30% reduction in mortality. from cardiovascular disease just in the last decade. nonetheless, as he pointed out there are things going on in

meaning, and this goes back to joe newhouse's point, when you're well, why wouldn't you want to recover and do everything you can to do that? when you are super ill, your preferences change a lot. and tracking those preferences, documenting them, getting them to the hhr and following them is coordinating care across time, and both of those have to happen. and, again, there are models there that do that. now, the second point is financing. again, back to joe. shared risk, shared savings probably is where we're going to end up. we have to have providers sharing risk with payers, and with medicare. but you can't just jump over to get there, because we're in the fee for service world, and it doesn't -- you can't just go from here to there. we're paying $20 million a year ourselves to put these teams in place in order to save medicare $2,000 per month, per patient. now, we're willing to make that investment, because we know we'll get, at some point, to shared risk and shared savings, and we're talking with cmmi about doing that, but the little providers out there that aren't integrated syste