How do that and travel . Quite frankly the only time i sleep is when i travel. That is how i do it. Thank you for getting us all fired up this morning and ready to take on the topic heard i am honored to be with you today as a pepperdine grad. I came for the beach but i stayed in Southern California because i had such a great experience at this school. I will go over some of the things i learned and user my i was excited to moderate this panel about the future of health care because it is something a think about in my business every single day. I think about value and Health Care Every single minute. The reason is because the lead organization that is helping to transform value on both sides of the economic equation and health care. We have systems and hospitals and settings of care come together to organize to be able to deliver clinically consistent incomes and to help move through the system. On the demand side, a big part of our client base our large purchasers of health care who work with unions, large employers and governments. They are looking at value a little differently. What im talking to my supplyside clients, there are a lot of conversations about the science, making sure we have the best outcomes. The demand side, the purchasers would rather that people never went to the supplyside in the first place. There is a lot of conversation about how we keep people healthy and engaged. What do we do to reduce the burdens that are required . We have learned over the years and you can see when i graduated i have learned over 27 years in health care that it really is local. That is true for health care as well. What is great for one population is not going to be right or exactly the same across the entire continuum of our country. There are some capabilities that are needed how to use data, how you use incentives, but what strategy is right for you, it is very specific to who you are, what your assets are, what is your service line, what is your place in the market, how much market share you have, what is the socioeconomics of the environment you are serving. , ws your service line, what is your place in the market, how much market share you have, what is the socioeconomics of the environment you are serving. All of that plays into your strategy. It is important to her thinking about how to drive Better Outcomes and you understand the impact of all of those factors. 27 years ago, when i had a finance professor at pepperdine, i got a job helping model alternative payment models. It was for the san fernando valley. Struck and completely hooked by how completely when the incentives were changed, they organized and drove it really well. Role lookingn that at models over the past 20 years. The aca has passed and we are starting to see an understanding that these things are needed. Theyre talking about unexpected partnerships, payers going to dinner. Ligands thats the conversation around the country is interesting. You see true anger. People are test at these town halls. You have people who want that coverage and people who feel like the coverage is just so expensive. So there is fear on all sides. One thing i want to make sure i keep in mind for myself is that the number one cause of personal bankruptcy in this country is a health event. Upon usthis real burden to try to figure out not just how we take care peoples clinical problems but how we take care of the whole person. Now, value has been very squarely focused in terms of the programs you are saying coming out of the state government. Now that macro is the first time the federal payrnment is saying he will individual physicians based on outcome as well. , to be able moment to perform under these programs is really critical. Were looking forward to introducing her to panelists. I think there is a lot of change, but one thing i think we all agree on is there is no turning back. The power of being a will to coordinate to create value has left the station regardless of what happens with how health care is financed ultimately. We now know the power to drive value. Introduce thed to ceo of the mayo clinic in arizona and the president and ceo of cedarssinai Health Care System. I will start with dr. Decker. He started as a chief executive the mayo clinic in arizona since 2011. He has been with mayo clinic for more than 16 years as a consultant. He has served in numerous leadership roles, including chair of the Mayo Clinic Department of emergency medicine from 2000 to 2008. Please join me in welcoming dr. Decker. [applause] tom has been the chief executive officer and president of cedarssinai and 1994. He has been associated with the Organization Since 1979. He was on the executive staff on montefiore hospital. Chairman as the past of the board of trustees and is the past chair of the American Association of medical colleges. Please welcome him. [applause] i will ask both of you gentlemen to kick off with a few opening comments. It is great to be here and i ,ould like to thank our host but also our colleagues at pepperdine for running this forum. It is really a pleasure. We started the day with a fascinating conversation on some of the nuances of health care, but also an overview that i think challenged us to think about the expenditures of health care and quality of care in the United States. One thing that we hear a lot about is how bad health care is in the United States. For some of us that does not quite tell the whole picture. I would like to start with a thought exercise. Beenr a loved one has diagnosed with an incredibly serious condition. Maybe it is a rare cancer. You have to get care and get there soon. How many of your going to book a flight to some other country because you can go anywhere in this world in this exercise are going to book a flight to another country to get medical care . Usually there are one or two because other countries have much looser oversight of experimental therapeutics. In fact, we see the United States actually enjoys some of the best Health Outcomes for complex conditions including Breast Cancer and cancer in the world. We have an incredibly expensive and it times fragmented system, there are pieces of the system that are really working well. I think that is something whether it is a national a localtion or conversation, that is something we dont want to forget and need to actually enhance. We want excellent in health care. The mayo clinic, one of the things we have been saying is wheres the voice of the patient . All of these conversations, where is the voice of the patient . Unique care 1. 3 million patients from every country in this union and 140 other countries who do fight to this country for their care every year. Here are some of the things we hear from our patients. They want access to care. They want access to centers of excellence. They want coordinated care. They want excellence with their team talks to each other and they want integrated health care. They not only want access but they do Want Health Care that is affordable. Here is another thought exercise is it always necessary is excellent and good outcomes always more expensive . Anybody . No, it does not have to be. Many of you are business people. You know the secret behind the solution to a problem where you want excellent quality and you want affordability is innovation. We need the ability to innovate. That is something that youre going to be hearing today. Many centers are really driving innovations and solutions. Aboutrd today a little the price of colonoscopies as an example of not only price variability but also an eye popper. In this country, 49,000 patients die every year of colon cancer. It is the second leading cause of cancer deaths in the United States. Of allt to a quarter eligible people do not get screenings for colonoscopies. I had one and it was great very [laughter] who all once a colonoscopy . Of haggling over the price of a colonoscopy, an Innovative Team came up with a totally different solution . Different solution that involves screening for micro amounts of dna in your stool . That technology was developed over 10 years at the mayo clinic. It was approved by the fda. It was licensed to a company that is now offering a test. I have no financial stake, but the Important Message is that a fraction of the price of colonoscopy and it increases access to screening. That with you as an example of how powerful innovation is and how vertical that it critical it is only continues, but we can help them flourishes so that they can invest in the nations future with solutions that work. [applause] that was extremely well said. Thank you, and thank pepperdine as well for inviting me back. When they asked me, i said yes. I think this actually is one of the best health care discussions of this type that occur in los angeles and in this region. I appreciate being part of it. A minute on cedarssinai. I want to do it for two reasons. One, i am a believer that where you stand depends on where you sit. Contextant to provide for the whole question of value. Integratedi is a organization that has a mission for patient care. There is an extensive outpatient side of things. Medical research not unlike what why it describes the mayo clinic conducts. Medical education. Extensive Community Benefit and Community Service mission. We are down to our last 2000 physicians associated with cedarssinai. Relevant to the later discussion, half of those are what i would call tightly integrated with cedarssinai. The other half are in private practice in the community in one way, shape or form. John aals have a joint venture between ourselves, ucla as a rehabilitation institute. Multiple and latorre facilities in the area. We happened to be the largest hospital in the western United States. It is not about being the biggest, but the best. That is what we strive to do. Combination of what you might call a Community Hospital. We are the Community Hospital for two to 3 Million People who live in the los angeles area. We are also the largest provider of tertiary and quaternary services. The most advanced in transplantation, neurosciences of any hospital in california. There is a common of the two of those things. Mix,rms of our patient about 40 of our patients are medicare patients, which makes ofthe largest provider Medicare Services in the state of california by almost a factor of two. For any individual hospital. A third of them are dual eligibles. Those are individuals who are elderly and poor. We are also one of the largest providers among private hospitals in the state of medical services. Maybe we will touch on a little later. Is, what we do and who we serve has a significant how valuebased care affects us, but more importantly , how we contribute into that movement. Very quickly, a definition of terms from a personal standpoint. Alleybased care is all about providing the best outcome for quality and a high safeway at an affordable price and the most costeffective way we as an institution can provide. This is something we are firmly committed to as an organization. Frankly to start, because we believe it is a professional and ethical imperative for the organization. For all of the reasons outlined in the opening marks, there is an economic in narrative the country in many ways. And listening to seek it reminded me that california actually has in in this valleybased care game for quite some time. It is fair to say more so than the rest of the country in one way, shape or form, having been in california since 79 and moving on from there. The Affordable Care act turbocharged valuebased care. Act,merican health care which is perhaps being voted on or has been as we speak, i think , frankly, has elements to it that raise question about the momentum around that, and maybe we can touch on that later on. Valuebased about care, i think of it in three ways. There is valuebased care at the patient level, along the lines of what wyatt and i have already described. But the issue of valuebased care at the organization lavrov organization level, and valuebased care at the system itself, whether it is the regional level, state level or nationally. Most of the attention today has been on the first piece of that, with regard to the patient level, and appropriately. To what is it was describing in terms of solving the differential between america and other countries, at least on the cost side, the issue of valuebased care on the patient level is necessary, but not sufficient to complete that journey without examining those other two elements. I think that the movement to valuebased care is fundamentally connected to having organized systems of care, organizations and structures that have capital and the management capability to bring to bear the kind of change that is involved in moving the country from where we are into the future. Oftentimessation breaks down into a debate about hospitalbased systems or physiciandriven systems. Frankly, i think that is a waste of time. There are multiple examples around the country of organizations that have their roots in physiciandriven organizations. There are organizations i have roots on the hospital side and there are some that have their roots on the patient side. Kaiser started as an insurance company, as many of you know. With regard to this question of valuebased care, with regard to both measuring with regard to measuring quality and in particular efficiency, i think we are early on in that journey. And among the things we hopefully will be addressing in the years to come are the Measurement Systems themselves. Thank you. Megan thank you both. [applause] so what we would like to do today is day further into the concepts that were just discussed. We will ask a series of questions to prompt the conversation. I think there is some conversation right now about the definition of feeforvalue. Specifically in your threezation, theres highlevel components we would like to discuss. One is what you were just talking about,. Tom. What is the talking about, tom. How do you engage Community Partners . Can you give us some thoughts on how physicians are looking at that and then we will look into population. At mayo clinic, we are a notforprofit organization. Our model is a little bit different. It is not unique, but it is not the most common model for physician engagement. Our physicians are employed on a flat salary. We feel, for our patients, what that does is it eliminates any financial pressures on the individual provider. So if you are a patient, its a gray area if you need your knee replaced or not. Youlike the comforter like they comfort knowing that there is no financial benefit to your Orthopedic Surgeon in deciding whether or not to replace your knee. In a feeforservice, that is the majority of how we provide health care in the United States. We reward volume and we reward doing things. That is how Medical Centers, including ours, make money. We like the implied physician model. I think one of the great things about the United States is we dont all have to do things that exact same way. But we do all want to make sure we encourage excellent outcomes. Ways. Re are multitude of one quick example is Medical Centers can affiliate. So we have the mayo clinic care work where we have centers we share knowledge worth. There is no direct to patient fees for these relationships, but allows mayo clinic to scale without having to do these massive mergers and acquisitions you hear about in health care these days. The past five to 10 years, there boon of mergere and acquisition activity. We feel that it is a missiondriven organization, focused around patient excellence, that we can do better sharing our knowledge than trying to own and operate Medical Centers all over the country. So there are multiple solutions. That has been our approach. Tom in the case of cedarssinai, we are different. I alluded to this in my opening remarks. Of the 2000 physicians, about 400 are fulltime faculty. These are physicians that lead our dear sherry and courts are sherry lead our services. We have some that are geographicallydistributed network. They cover a 15mile radius around beverly boulevard, for those of you who know where cedarssinai is. What i would observe about the work, and i agree with the observation that it is not about anyone particular model that lends itself to success. In fact, i am always intrigued when i hear colleagues say you employ your physicians. It would be easier for you to make change. Im here to tell you that is not true. [laughter] that is not absolutely true. Process, whether the physician is employed or in private practice, has all of the same elements that zeke referred to in john carters work. The change process is that change process. What i would say is, with those for decisions that are more for those physicians that are more integrated with the institution, one, because they are more active in the integrated work of the entire organization, the process of change related to shared vision and the kind of things that go a long and follow from that, the physicians that are in a more integrated relationship move through the change process, in some areas more quickly, in other areas not. The other element has to do with the ability to bring to the ambulatory environment the kind of characteristics you saw in the 12 prescriptions for American Health care in the future. In the case of our integrated physicians, i would be happy to share with you that virtually all of those are underway and have been at cedarssinai as part of a long transformation to valuebased care. In the case of our have it, these are all independent businesspeople and they are making all their own choices about how and where they fit in this valuebased care in equation. The part we can impact, and other credit and to their great professional credit, is the private physicians are in line with us with regard to the valuebased Care Transitions we are making, w