Mortgages. That is going on today . The deadline is tomorrow. In the legislation, we band the bad kind of mortgages. They said i was keeping poor people from buying houses in subprime was fine. That is exactly right. You can read it. Es copies for everybody. Secondly, to the great bulk of mortgages, they were qualified mortgages. Those mortgages, you would be able to secure them, but we asked for Risk Retention. Five percent of the risk would have to be retained. That would incentivize them not to provide junk. Because of senators, democrats, listening to people in the mortgage industry, would put in a qualified residential mortgage, stupidly confusing. Those mortgages were supposed to \those mortgages were supposed to be a supersafe category to securitize. To my dismay, the major proposal of the five regulators is to convince to combine the two, the other you can make without Risk Retention of any case. You heard that before. This is been the single biggest cause of the problem. I am hoping that they can be dissuaded and have Risk Retention as a rule of argument. They dont know how to make mortgages without Risk Retention. It apparently means no mortgages were made in america before 1980 when i came in. We are going to leave it there. This is been a remarkable three. Thank you for the conversation and the questions. [applause] [captioning performed by national captioning institute] [captions Copyright National cable satellite corp. 2013] on the next washington journal, discussing last weeks Virginia Governor race. Our guest is matt lewis. After that, rob richie with the group fair vote. He talks about the gridlock on capitol hill. Later, a conversation on u. S. Surveillance abroad, and how it is affecting diplomacy. The council on Foreign Relations joins us. We will look for your comments by phone, email, and twitter. Washington journal is live every day at 7 00 on cspan. A Senate Hearing on wildfire prevention. How they have paralyzed impacted hospitals and quality care for patients. This is 45 minutes. Before i get to the topic at hand, i didnt want to miss the opportunity given im sitting next to someone who could not be better positioned to give us some thoughts as to how things are going with the moment occasion of the Affordable Care act. Leader of a large academic ads institution, i wonder if you would give a grade to the implementation. Im glad i am a cardiologist. It has been very tough. If we not to do anything, when we know how to do software. To see whether this is going to rollout, which i think that it is look at the states theyre doing it themselves. They are ready have the platform. Theyre registering hundreds of thousands people for medicaid. The ones that are running their own exchanges have them up and going for the most part. We do not have enough of them that are running their own exchanges are registering people on medicaid. I think we have enough time that we are going to get it right. We must have everybody enrolled. There is no way that we are going to be able to continue the Cost Shifting that has been going on our we are going to be will to deliver the things we have talked about unless everybody has insurance. It has to work. The technical problems are just that. Technical problems. I havent heard anyone say that they are designed problems. We know we have large numbers of uninsured. We know we have to get insurance. We know some of the need to be subsidized at the end of the day. We are going to have to get that done. I think there is enough time to do it by march 1. Do not know if anyone wants to i will just turn attention away from the hot topic of the day. An interesting thing in the post this week in, it was an article about implementation of the whole Affordable Care act. They cited a letter that david cutler sent to the Administration Early on after the law passed. It was interesting to me that one of the things that cited was not enough attention to provider engagement and getting the Provider Community bought into all of the changes ever going to have to take place. You lead one of the largest provider organizations in the country. If you think about the transition ahead, and making the changes that will be needed, how do you think about those challenges question mark how we manage to get from one side of the river to the other . Anyway that allows us to continue to bring in great care . I would amplify about the implementation so forth. It is a relief. We have to be patient. We will get everyone it needs signed up. Living this new cycle and instant gratification by everyone, we are all appear with our cell phones and blackberries, and we need instant gratification now. Big about when medicare was introduced. I think we have to be patient with that. This is a big question about engaging with providers. I think the kind of comments, the doctors do what you pay them to do. This is going to be a change in focusing on delivering the highest quality care while at the same time providing excellent customer service. That is a different paradigm. I think it is going to be an educational process, a changing of the culture. Think about the large hospitals that have multiple Product Private practitioners or inside a university system, where even the university does take into account quality often times in the promotion of an appointment process. It is going to be a big change, and there would be bumps in the road. We changed to reward the bull basin quality outcomes. We have never been charged with doing that. We just want to do as many big volume cases that are cases. That is going to change. One of the things that i am concerned about is when you use volume as a metric for reimbursement, to have a level Playing Field to define what the quality parameters youre going to use. One of the things, data came out of new york that was exporting of the difficult cases west of the cleveland clinic. I think that whether by design or just by circumstance, there may be a de facto rationing built into this because we are not going to take on the tough cases and not offer the services. We know we need to get from one side of the road to the other. I think everybody is clear that we need to say we are paying for value. Is not aware we need to go that is a problem, it is how we build the economic model. Im still, as we heard earlier, a lot of my business is still in feeforservice. How do you think about managing the transition economically . Im going to escape to her think the puck is going to be as Wayne Gretzky said. We think about the implications of how to decrease readmissions as toby was saying and how to manage chronic care outside of the hospital. I think there has to be an incentive put in place that changes the behavior of providers. As were speaking earlier, there has to be some shift also to taking away some of the things that physicians have done in moving it down to extenders, whether it be nursed practitioners, nurses, pharmacists are working together as a team. But an incentive that drives behavior. There is a recent paper verifying the surprise that pay for performance actually changes professional behavior. One of the things that here is that we have to get out of being in the Hospital Business and in the care continuing business. To think about the whole patient across all that sides of care. You have been a leader in your private business and in the policy world and thinking about how to rebuild out a more robust continuum of care in different settings and get patient involved. Help us think about what that means for hospital. Is your party touch on the big changes. People ask me all the time with the biggest change that we are undergoing. Metalico the change today. I think the biggest change that we are seeing that can be transformed the shift in risk. Money flows, winners, losers, also efficiency and waste. Risk used to be in the purview of government of the big pay orders out there heard with obamacare big celebration, the risk is shifted to the providers, the hospitals, the doctors. That is what is new. Hospitals dont know how to manage risk. It never had to do it. Now it is in the providers. So the hospitals are what were are talking about for the next couple of days. The consumer is the new element. This consumer is going to be for you stay competitive in this new world. Youre going to have to focus on consumerbased experiences that go all the way from scheduling, how easy it is to see a physician or a team come how long it takes, how you were treated. Much data is given to in your pda and your personal device, do you get Laboratory Tests before or after, what is that followup to keep you not in the hospital but out of the hospital, which means the hospital is no longer a structure, but like bob says it is an integrated system to keep people out of the hot the high cost to a low cost side of care. Im optimistic about that. I think the government has made think the government has made a disaster over some very good principles in obamacare so far. Time to recover, but we will see. I think the leadership has been poor, it has been laid out poorly, it hasnt been done well here it am very optimistic and heres why it is so important what youre all talking about the next several days. Technology today, ipads didnt exist three years ago. Now you have a hundred million out there and we all depend on them today. 94 of people have telephones and 54 have smart telephones. The associate economic that empowerment of data, and data is not Electronic Health records. Information technology is not Electronic Health records. Government pushed a set way. Information technology which is going to drive the innovation which is going to be consumer driven, not driven from above, is going to be automation, Decision Support to make sure the right decisions are made with the resources that are available by doctors at consumers. It is going to be the connectivity which means an investment to get those tentacles out there to do the Outpatient Care inpatient care. The big data means data mining, the sort of stuff we couldnt do before. In some ways to stay competitive youre going to have to have consumerbased experiences. The consumer is going to be technologically savvy in terms of prevention care treatment and it will be driven to the connectivity and automation in the Decision Support in the data mining that is available. If we use is effectively, you can stay competitive and patients can have better outcomes. One of the ways that consumers get to help care is through the employer and to the pay or indirectly. What doctors i can see, what hospitals i can access heard a lot of the benefit structures are determined by employers. That is changing now a lot of the way employers are purchasing healthcare is beginning to change. Employers are getting impatient with cost of healthcare in the traditional benefit structures. From your perch, thinking about benefits for employers large and small, where do you think the purchasing behavior drives a Hospital Business in the healthcare business. How is echoing to change over time given where employers are going . Employers have always been uncomfortable with the rate of inflation in health care, but theyve always manage to pay. Are the outcomes of the aca is the excise tax cap that hits in 2018. You can complain as much as you want about the law, but gives you an out as an employer. Ive yet to meet an employer is going to pay the 40 excise tax on the system that the already consider efficient. We have established a ceiling that employers are willing to pay. I think what the senator pointed out is that consumers are going to be exposed to more risk. It is going to come in one form or another. When people start to see how much more theyre going to have to pay tour only two ways for an employer to stay. The unit you have to raise deductibles or outofpocket limits. As a general rule of thumb for every dollar you try to stay under him premiums have to increase maximum exposure to participants by two dollars. If youre talking about 50 is not a big deal, but if you talk about a thousand dollars thats a huge exposure. If youre a hospital that is a huge exposure and uncollectible debt. The second side is if an employer doesnt do it by increasing exposure to participants, theyre going to have to focus on much narrower networks. Right now the whole Network Selection criteria has been make sure my doctor is in, make sure my hospital is in and make sure all the others are in, too. Most of the networks around the country are established to include everyone. I think what were starting to see on the public exchanges and we look expected an employer around is a lot more of these specialized narrower networks. If you try to go to a Large Employer occupation and sarah will give you access to 50 of the providers in the community, there is an upper. If you go to an uninsured population that is had no covers before and say im going to give you coverage a half of the providers in the community, that is a win for everyone. I think as those networks are to get filled, people that are in these bot access net shipment of access problems of their own, you may go to a less efficient provider. So there is a lot going on in the employer community. Not just about how we do it smartly because theres a plot of moving dynamics because the uninsured have access to health care. That is good to be a take issue for people. This change in high deductible, there are some good things about that. I does bring the consumer in. The consumers we are going to be bringing in for obamacare to work is going to be a younger population. So deductible five years ago was probably 500. Now it is 2500 for most companies. So 30yearolds are going to be forced today, mandated to get everybody in the insurance pools who will have deductibles of 2500. Plus they will be paying a thousand to 1500 and theyre going to be the ones going to the pocket, pulling out an app and pushing a button and saying ok. I need an mri. I have my physicians as a do and push a button it is going to cost 2200 at the center over here with very well known Academic Health center in 1200 in green hills and 300 next door. And the quality is the same on the same machines and this button is telling me that. All of a sudden its going to have a huge impact in terms of the power of the consumer who is empowered with a bucket of money now, namely their own money, to shop and the system is going to have to respond. To me that is going to eliminate waste, inefficiency. 30 of the three chewing dollars being spent today that doesnt go to federal Patient Outcomes, to me that his rate positive. Of course i am more optimistic about the future, but technology will allow and empower the consumer to make those decisions. I think it is a really important trend. If you are a highcost provider, that say a Large Academic Medical Center or a big specialty practice, you are probably at the high end of that pricing list on the app. Lets just pause which is positive the transparent world, the prices are going to a lower level. As revenue that is supporting a lot of other things going on in medical centers. I wonder, from the perspective of the university of miami, how you think about the economic pressure that this puts unsustainability of these important centers . There will be tremendous pressure. Particularly when the government is reducing the amount of Research Money that is coming in. You have no place to cost shift to. The fact is, were going to have to live in the real world. We are going to bring our costs down at the same time. Were going to have to eliminate overhead and do all the things that other providers have to do heard im closer to the employer than the provider, so i see it from both sides. I dont think Academic Health centers will get off the hook. If we are 20 more expensive now, were going to have to bring it down so that we can compete did i would point out, though, that most people who come into medicare have not have a lot of choice. So theyre really coming out of hmos, out of narrower networks. So moving medicare to narrower network, moving medicare to less choice, may not be as big a jump as some people would suggest. I would, though, say a word about people that cant afford high deductibles. We have used we have to be very careful about Price Sensitivity for poor people, for old people. Youre bringing in a lot of young people into obamacare, but we are also bringing in low income workers. With that group were going to have to be very sensitive about whether theyre really going to have real access to Health Care System if they come in with high deductibles. It will be just as bad as the Current System for them. That is what makes it so complicated. The different kinds of patients and people that we are doing with, some of them can live in a world with very high deductibles and others are going to have to be looking forward. Or we will end up with lots of charity care for the in betweens. I would echo what President Shall ayla says. Of what president shalala says. Some of it is made up by the more prestigious places through philanthropy recruiting talented individual to get more grants. You can never make up the overhead by just indirect costs coming back from grants. I am concerned are there has always been this healthy tension between the dean of the school of medicine and ceo of the hospital about fans blowing how you support the academic mission. That is going to be even more difficult as time goes on. I agree that in order to be competitive, the inefficiencies within academic medical centers, particularly hospitals, and a lot of it has to do with trainees responsibility and ordering too many tests are not the right tests, were going to have to fix that. There has to be a lot of attention. I think that the really good places will get this figured out and it is