one thing to note in particular is that congress intervened in 2015 with macra. the intervention was essentially designed to get rid of the sustainable growth rate, sgr sustainable growth rate. a lot of people thought that was the beginning of this kind of payment control system that they actually replaced a predecessor program with a better name something called the volume performance standard, a government name that works? that's the one. this has a long history but when they replace this in 2015 with macra, the curious thing that i'm still scratching my head about is that physicians agreed to support the package on the notion we would get rid of the , that had been living for years, but the end result was, the payment system they put in place has a lower long- term baseline and a lot of people don't understand that, because they put the updates for the physician fee schedule at a default rate of point to 5% annually forever. , if you're lucky enough to find yourself into the alternative payment model its .75. so, the baseline is now essentially well below what

known macrae open and will listen to me and never been there when you have a think of it in a state. where you know you're feeling all going on in new york. but just a funny thing is more than a dream she leads a group of young people fighting for immigrant rights in the states with a very conservative government and legislature and of dreamers no i'm afraid i'm afraid long legs but in few months ago she took part in a hearing to convince texans senators not to pass a law that would be tough on undocumented immigrants my little i don't know how you said but i will go to do i got be done but hasn't gone through this i would have and i did i want to hear him say bunk good luck in the document. if you got to move you on us. as we only go. this then it must. have also built them in the usa i press on us here i must give you about this is one of the most almost gave all. the press have done this you also notice that mickey. said this the. no known as and it is but i don't know what that is. but i sent this book at almost halfway on time but. yes mass or not. the state your yes. may i want

from requirements around ehr's to new regulations under macra. independent physicians are increasingly selling their practices to hospital systems and new physicians often start their careers at employees of larger systems. and according to a survey, by the american medical association hethe percent of clinicians with ownership status in their practicest declined from 53% in 2012, to 47% in 2016. with young physicians more than three times as likely as older physicians to be employed by hospitals. now consolidation has downstream effects in the healthcare system and impacts patient care. they have fewer choices and higher prices. and physicians often have less autonomy in consolidated systems. we have seen cases of large systems controlling referral patterns to keep patients in-house regardless of whether it's the most convenient for the patient. as schools continues patient choice and freedom takes a backseat. president trump's executive order promoting healthcare choice and competition, empowered cms to focus on this trend and bolster competiti

but when they replaced this in 19 -- in 2015 with macra, the curious thing that i'm still scratching my head about is that physicians agreed to support that package on the notion it was going to get rid of the sgr cuts that were looming and had been looming for many years. but the end result was that the payment system that they put in place has actually got a lower long-term baseline than the sgr system. i don't think a lot of people even understand that. and it's because they put the updates for the physician fee schedule at a default rate of, get this, if you're in the mips program, .25% annually. forever, okay? [laughter] and if you're in the, if you're lucky enough to find your way into the alternative payment model, it's .75, okay? so the baseline for physician fees is now essentially well below what's probably realistic. and so on if we -- even if we correct some of these problems, there's a massive, long-term problem that is going to have to be dealt with one way or the other. i hope we can talk about that that a little bit in our discussion. now, you know, how to did this ha

reducing readmission rates, more cost effectively supporting those end of life needs, and with the macra, providing those added benefits to help enhance the member experience. and then, a chart on page seven, i'm obviously not going to walk-through it, but this is a helpful side by side to look at topics within the framework of providing coverage for medicare retirees and how those are handles between original medicare and medicare advantage. and in the medicare advantage you'll see there's some reference to h.m.o. models and p.p.o. models. here in california, we offer one of each. kaiser is an example of an h.m.o. model, and northern chasm, but also available to your retirees across the across is the uhc-mapc program across -- across the country is the uhc-mapc program. in present state, there's almost 20 million that are in the medicare advantage environment, taking an m.a. plan, and you can see how that population has almost doubled since the stooart of this deca. this is really highlighted on slide nine. when you look right now, we're really right in the heart of baby boomers ageing

this has a long history, but when they replace this in 2015 with macra, the curious thing i am still scratching my head about is that , physicians agreed to support that package on the notion it was going to get rid of the sgr cuts that were looming for many years, but the end result was, the payment systems they put in place actually got a lower long- term baseline then the sgr system. i think a lot of people don't even understand that. that is because they put the updates for the physician schedule at a default rate of 0.25% annually. forever. and if you are lucky enough to find a way into the alternative payment model, it is 0.75%. so the baseline for physician fees is now essentially well below what is probably realistic, and so even if we correct some of these problems, just the overall structure has got a baked in massive long- term problem that is going to have to be dealt with one way or the other. i hope we can talk about that a little bit in our discussion. how did this happen? swell, again, how to get past the short-term problem of the sgr and without thinking necessarily