Transplants and big surgeries and things like that. One of the things i am concerned about is when you use volume, it is a metric for reimbursement, to have a level Playing Field to define what the quality parameters you are going to use. One of the things, especially with toby and bill and i, with cardiac surgery, and we saw this when the recording data ,eally reporting data came out the cases is west of the cleveland clinic. By design or by circumstance, maybe there will he be a de because of the tough cases and not offering services. So we know we need to get from one side to the other. I think everybody is clear we we are noto just paying for volume, we are paying for value. We need tohe where go that is the problem, it is how do i make the economic model work from here to there. I am going to be taking on risk for quality and cost and so with fee i am still forservice. How do you think about managing that transition economically . The good places are already along these whole Wayne Gretzky thing, skating to where the puck is going to be. 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. We were speaking earlier. There has to be some shifts also to taking away some of the things that physicians have done and moving it down to extenders, whether it be Nurse Practitioners, nurses, pharmacists, all working as a team. That incentive that drives the behavior. There was a recent new england verifying that payforperformance works to change peoples behavior. One of the things i hear from Hospital Leaders is that we have to be out of the business of being in the hospitals. We have two think about the whole patient across decisive care. You have been a leader in your private business and in the policy world of thinking about how do we build out a more robust continuum of care in different settings. Help us think about what that means for the hospital. I think we have already touched on the big changes. I think the introductory comments people ask me all the time about the biggest change we are undergoing. Biggestto look at that changes for the hospitals of the future. The biggest changes that we are saying that can be transformative this shift in risk. With risk flows capital, flows money, flows investment, flows winners and losers. Risk used to be, in the purview payersrnment, the big out there. But with obamacare, the acceleration, the shift was underway. The risk has shifted to the providers, the hospitals, the doctors, and eventually consumer. Hospitals do not know how to manage risk. They have never had to do it. It has been did it has been the government, the big payers. Now it is the providers. To be theer is going new element, and the consumer is stay to be for you to competitive in this new world, you are going to have to focus consumerbased experiences, which go all the way from scheduling and toby went through some of them all the way through scheduling, how easy it is to see a physician or a say or 18, how long it takes, how you were treated. Do you get Laboratory Tests before or after . What is the followup to keep you not in the hospital but out of the hospital, which means a hospital is no longer a structure, but it is an integrated system to keep people out of a highcost to lowcost more appropriate side of care. I am optimistic about that. I think the government has made a disaster over some very good principles in obamacare so far. Trying to recover, but we will see. The leadership has been laid out worley, it has not been done well. But i am optimistic, and here is why. Here is why it is so important with what you are talking about the next several days. Technology today ipad did not exist three years ago. It did not exist. 94 of the people with telephones, 54 of people have smart telephones. The economically underserved have smart phones today. That empowerment of Data Information technology is not Electronic Health records. Government pushed us that way. Information technology, which will drive the innovation, which , is be consumer driven going to be automation, decision , support, to make sure the right decisions are made by doctors and consumers. It is going to be the conductivity. It needs in investment to get the tentacles out there to do the outpatient or inpatient care. Big data means data mining, the sort of stuff we cannot do before. Competitive, you will have to have consumerbased experiences. The consumer is going to be technologically savvy in terms of prevention, care, treatment, and it will be driven through theuctivity, treatment, and data mining available. If we use those event if we use those effectively, you can stay competitive and the patients will have better outcomes. One of the ways consumers get to healthcare is through the employer, and the payer indirectly. What doctors i can see, what hospitals i can access, and a lot of the benefits structures are determined by employers. Hat is changing employers are getting increasingly impatient with the cost of health care, and the traditional benefits structures. Where do you see the purchasing behavior driving the Hospital Business and the health care business. How will that change over time . Given where employers are going . Beenployers have always uncomfortable with the rate of inflation in health care, but they have always been willing to pay it. You can complain as much as you out asut it gives you an an employer. I have yet to meet an employer that will pay the 40 excise tax on a hip. Lets establish a ceiling that employers are willing to pay. Thesenator pointed out that consumers will be exposed to more risk, and it will come in one form or another. When people see how much more they are going to pay, because they are only two ways have to either raise deductibles or outofpocket numbers. For every dollar you try to stay under in premium, you have to increase maximum exposure by participants to two to two dollars. 1000 is a huge exposure. That is huge exposure in uncollectible debt. The second side of it is if an employer does not do it by increasing exposure to participants, they will have to focus on narrower networks. The selection criteria has been make sure my doctor is in, my hospital is in. Most of the networks that you look at around the country are established to include everybody. What we are starting to see on the public exchanges, we start to see them move into the employer realm, are the specialized, narrow networks. The Larger Population says i want to give you access to the providers in the community, there is an uproar. But if you go to the uninsured population and say i will give this side of the community, that is a win for everyone. They will have access problems on their own, they go my to they might go to a less efficient provider. How do we do it smartly . There is a lot of moving dynamics now that the uninsured have care. That will be a big challenge for people. Change ing on this the high deductible, there are some good things about that. ,t does bring the consumer in and the consumers we will be bringing in for obamacare to work is going to be a younger population. So a deductible five years ago for most of your companies was probably 500, and now it is 2500 for most companies. So 30yearolds will be forced today, mandated with deductibles of 2500, plus they will be paying 1000 or 1500, and they are the ones who will be pushing a button and saying i need an mri, i have to pay for it for the first time. Because of my headache, because my physician says i will need it. It will cost 2500 at the center over here, 1200 over at andnhills, 300 nextdoor, the quality is the same on the same machines, and this button is telling me that. All of a sudden it will 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 will have to respond. That is going to eliminate waste, inefficiency. The money that is being spent today that does not go to better Patient Outcomes so to me that is very positive. The technology will allow and empower that consumer to make that decision. I think it is a really important trend. If you are a highcost provider, and Academic Medical Center or a specialty practice, you are probably at the high end of that pricing list on the app. In a transparent world, pricing will drop to some lowerlevel. That is revenue that is supporting a lot of other things. Hat go on in medical centers i wonder from the perspective of the university of miami or tmc, how do you think about the challenge of the economic pressure that that kind of transparency and consumerism puts on the sustainability of these important centers . It will put tremendous russia, particularly at the same time the government is reducing the amount of Research Money coming in. We have no place to cost shift to. The fact is we are going to have to live in the real world. We have to eliminate overhead and do all those things that other providers have to do. Employer and a provider, so i see it on both sides. I dont think Academic Health centers will get off the hook. If we are 20 more expensive now, we have to bring it down to compete. I would point out that most people coming into medicare now have not had a lot of choice, so they are coming out of hmos and narrower networks, so moving that moving medicare to a narrower network, moving medicare to less choice may not be as big a jump as some people would suggest. People say a word about who cannot afford high deductibles. We have to be very careful about about pricey sensitivity for war people, for young people. We are bringing in young people, but also low income workers. With that group we have to be very sensitive about whether they will have real access to the Health Care System if they come in with high deductibles. As the be just as bad Current System for them. At is what makes this so complicated. The different kinds of patients and people we are dealing with some of them can live in a world of high deductibles, and others we will have to be careful with or we will end up with lots of charity care or the in between. I would echo what President Shall a lot president shalala said. Always cost centers, not profit centers. Up of moreis made prestigious places through philanthropy, but you can never make up the overhead budget indirect costs coming back from grants. I am concerned, and there has always been this else the tension between the dean of the school of medicine, the ceo of a , how you support the academic mission. That is going to become even as time goes on. I agree that in order to be competitive, the inefficiencies with the Academic Medical Centers, particularly hospitals and a lot of it has to do responsibilities, ordering too many tests. We will have to fix that. My view is also optimistic about that. Theyre really good places will get this figured out, and it is starting to happen. Toby shows that graft about the consortium. The federal Academic Medical Centers have not been ranked as highly. They are focusing on that now in improving quality and cost. That will be the ratio we have to watch. We took 900 physicians out of our Academic Health center, and they were all administrative. We did what major corporations are doing and we looked at our staffing, and we protected the clinical side, but we took a whole layer of administrative recurring probably 40 million or 50 million in recurring costs. We had to do that because we are seeing what is coming down the pike. We will have to be a more efficient organization. We are employers, too. Highcostafford academic medicine as an institution. I think the Academic Health center you are both very involved there. For most people in the room, we all need to define our goals. The goals today are patient outcome. We have always said that, but now for the first time over the next five years, reimbursement will follow outcome of the patient over a continuum of care increasingly with bundling and reimbursement for one of your post transplant increasingly we are going to move to a more reimbursement. If you look at the hospital of tomorrow, it will be maximum outcome for maximize outcome for existing sources or maybe less. Yours is different because it is maximizing patient outcome, but you need to train the cardiac surgeons of the future and the primary care physicians of the future, and the nurses of the future, and the teambased approach. And research. And the third column is research. The 60 to justify billion of research or whatever it is going to be. And the role of training people who have a teambased approach. Forget the way i was trained, the way bobby was trained. There is a teambased approach where nurses and social workers are elevated, responsible for more of the population than the individual. Because by theff time they get out in the real world it is too late. For most people, the hospital of tomorrow is not going to be miami or even cleveland clinic, but it is going to be the other 4000, 5000 hospitals that have to survive. That survival is going to be Patient Outcomes measured. That will be driven by primarily , twomer experiences hundred Million People changing the system instead of a hospital ceo. Do we need 500,000 hospitals in that world . Probably not. Trillion, has been 3 much of it is wasted. 5200what ever hospitals out there in each trying to be a comprehensive hospital with as much marketing to attract patients through marketing . That is the old way but it is pontiac and the airlines, in terms of delivery yources, how you go to get airline reservation. It is not the Way Financial Services has gone today. That is going to be the difference. If you had appropriate allocation of resources, where every hospital did not have to offer all 20 different services, of course you do not need 500,000 hospitals. We have seen it in all of our communities, this arms race of if one hospital gets the latest, greatest m. R. I. Scandal, mri scanner, and the others have to have it. I think that is going to be over. Most hospitals in the country, they are in the lowsingle digits, and a lot of these hospitals are not going to be able to survive, nor should they. I do not think we need all of the hospitals to answer your question directly. But it will be difficult to make if we are not part of the system. So we have to change the model of care, it sounds like. We are in agreement that we cannot deliver care with the same highcost, so we have to figure out how to distribute the care, more teambased care, and so forth. But hang on a minute, where are all these deliverers of care going to come from . We will not have enough doctors, surely, to deliver all the primary care over the next 15 years. We do not have enough nurses today, and think about where demand is going. Development, secretary shalala the numbers out there, 0 primary care doctors, too short of the next eight years. 40,000 doctors are needed today. Before, if obamacare is fully implemented. Another 30 Million People coming into the system who do not have insurance. When somebody comes into the system, their Health Care Spending goes up 50 more than what they spend through the system. So 30 Million People coming into a system that the 40,000 primary care physicians before you factor them coming into the session. Donna, what do we do . [laughter] we start thinking about how people are trained and allow people to practice up to their training. The fact is that Nurse Practitioners can handle about 70 of the primary care. We should be using welltrained primary care doctors for more of the ambiguity, and this is the point that a bill that bill and everybody else has made. We have to create teams, and that means physicians assistants and nurses and pharmacists and other care providers working as a team. We have to get over the hierarchy. We have to take on the scope of practice rules state by state if necessary, because that is what restrains us from creating these teams in many ways. We have to look at how people are trained and trained them better. The fact is we could handle this primary care if we could deal with the practice issues in almost all of the states. If we can overcome our reluctance we talk about teams as opposed to hierarchy. Will we have to train people in the future . Yes, but we have to use them up to the level of their training, and i think we can handle it. Most people when they are brought into the system have to get health care one way or another. People run to the doctor to get their physicals that can settle in with very good nurses and physicians assistants and the teams of caregivers to organize primary care, Chronic Care Management to the endof life care. There are lots of things we can do if we can break down the barriers across the board. I think the policy is important, but it starts more fundamentally. Doctors do not like teams. You have a patient coming into the door, the other surgeon steps in, and you have to fix it. And the teams that have to sit around listening in a collaborative way to other people, we just want to cut, fix some i get it done. You are talking about surgeons. In all seriousness, that is a transformation. Our professional ethics is not to be teambased. Today,ctice of medicine medical schools are not trained. Business school is trained with six people to address an issue, get an outcome. That is not the way doctors are trained. They probably are now with both of your centers, but they really are not trained very well to be a teambased approach where you are taking care of eight doctors are taking care of 5000 not 1000and patients. That is going to be, after my the thirdformation, big transformation is going to be teambased. We are not there yet, and everybody in every hospital needs to encourage it. You have to integrate social workers and integrate even the epidemiologists and the presented the Preventive Medicine and the yoga specialists, and doctors do not like it. Patient safety in the readmissions issues we have been forced to put teams together to drive down those costs so that we were not penalized. I happen to think in one sense we will change the culture t