What do you think is the bottom line in terms of what cbo needs and how should the Public Health community the thinking about it . William h. i think you should ask the former director before you ask me. This is going to sound like a bureaucratic response. As a former cbo staffer but resources, honestly. Resources. I know it is a throwaway, but the need to weigh come as part of this activity we met with cbo staff. I was shocked at the number of Journal Articles they have to go through every week. 1000 Journal Articles, if you can believe it, just to weigh in. I concluded out of that discussion that what they need is a watson ibm program to condense at least narrow it down so they can find out evidence which is replicable, scalable at the National Level. I note it is a throwaway, but they need resources if they will translate this into actual good evaluation of the policies and forth. I want to pick up on something that jeff said, though and bill, too, to some extent. The problem as i see it is prevention is not homogeneous out there in terms of the communities. In some communities one prevention and intervention will work better than some others. It is difficult of a National Level to press National Policy that can be replicated in terms of the cost estimate. Lisel alice . Alice i would second bills feeling that the Congressional Budget Office needs more resources to you now you wait the evidence to evaluate the evidence, because the evidence on whatever it is on health intervention, prevention intervention is getting to be voluminous. But that said, what they really need is convincing evidence. And i alluded earlier to some of the enthusiasm for who would love to pass a bill that says for example, we should take available to every county in the country, and there are several thousand of them, resources to do what Hennepin County is trying to do. You could draft such a bill. And eventually it would if it got out of committee or even serious consideration in a committee get to the cbo and say what with this cost and what would the benefits the . Be . The cost wouldnt be very hard because you would specify what that was to be, when you are going to give all of these counties to do this thing. But what is the benefit . They would be driven back to looking at the county. Can we say that spending this money would improve the health of Hennepin County . If you can definitively say that and if you thought you could replicate it in several thousand other counties, then the problem would be simple. But neither is true. You dont yet have the evidence about hennepin and you arent sure that what has made it possible for them to at least get a start was the peculiar to Hennepin County. That wasnt peculiar to hennepin that wasnt peculiar to Hennepin County. That is the dilemma that cbo had to face and i think they do a pretty good job. Jeffrey i think there may be more evidence out there than we are accessing. Hundreds of millions of dollars worth of investment in Community Prevention programs that was evaluated. And those evaluations have not been released. Community transformation grants was supposed to be a fiveyear program and was topped after three years so it is hard to do a full evaluation. But there was substantial evaluation money put into that. We have yet to see data from those. There is also an obligation on the part of federal agencies who are investing hundreds of millions of dollars of taxpayer dollars and who have been directed to do evaluations to release those evaluations. Alice oh, absolutely. We need to know that. Jeffrey we need to know that. That isnt always the case on the clinical side. We tend to publish clinical results. But we are more open on the Public Health side. We want to know what works and what didnt work. We learn from those examples. What is wonderful about things Like Community transformation grants and partnerships to improve Community Health is that while they have the same targets, communities are taking varied approaches, evidenceinformed approaches, but various approaches to reflect the needs of their communities. But if we arent releasing what we are learning from that, then we keep redesigning new programs in the dark. Putting aside cbos needs, it is just not a wise investment of taxpayer dollars. Alice but it would help cbo to release that coul. William d. but waiting for cbo is like waiting for godot. [laughter] how do you settle for communitybased data, which is really based on a randomized trial . What is the level of evidence necessary to convince cbo . And back to jeff, i think there are other mechanisms that we are and not to be pursuing at the local level through the Community Benefits initiative of hospitals, which we need to w rap in, and there are mechanisms in place through the Affordable Care act to direct those hospitals to invest in Community Benefits and do Community Health needs assessments. Likewise, and this is a question for you, it seems to me that more flexibility on the part of medicated to fund the pilot programs that jeff has described, and certainly the ctg and cppw are implementing, would help to move the field forward. What are the likelihood that that will happen . Jeffrey you brought up Hennepin County. The idea very simple at its corporate you take all the money this is the idea at its core. You take all the money at the state level and wipe your hands clean and it is their job to do with that. They are the most context patients to deal with and they have been charged with doing that. They have certain unique advantages, that those patients are automatically enrolled in the program. You dont need to find anybody. They are yours. There are specific governmental structures that allow types of data sharing that are not necessarily present in other communities. The other thing is that the state has been very generous. While certain states have materialized, they have not had to pay that back. Those are the unique features of that particular program. It makes a lot of sense. I referred to the fact that i was apparent. I have two kids. The one kid i give 10 to come he says that money saves that money, and the other kid buys coming outs and is totally not responsible. This is the problem we deal with. Freedom is good, we believe that. However, in health care, there are big dollars involved. Not all actors can be trusted. If hennepin is so great, why doesnt that exist already . We have medicaid cbos. Incentive already exists. We as a nation and as visions ourselves are still uncomfortable with giving that much freedom away, or freedom without necessarily asking for a lot of accountability in return. How is it that you measure that accountability . We talked about having Population Health or clinical metrics. For those you go online right now and can go to places for quality of the hospital. Real patients often dont feel that the data really gets to what it is they really care about. I would just say that part of the issue is yes we want to move the nation that is what moving to valuebased payments is all about them if you look at how we have lay that out, but we think it has to be done very deliberately. And although the pace may seem like why dont we just directly passed the resolution to give everybody black granite payments, there is a downside to that. This is one of the reasons why we feel like doing it in a somewhat more studied and deliberate manner is going to be better for most patients. Jeffrey i agree that it is not just a question of throwing money out there and that is not the hennepin model, but it is also inaccurate to say that medicaid patients can do what hennepin is doing already. It brings all sorts of resources to the table that then get better integrated, and your typical medicaidmanaged Care Organization does not have the resources to do it, doesnt have the authority to do it doesnt have the capacity to do it. That is where it is fundamentally different. Lisel that brings us back to where the task force ended up you this exchange illustrates the issues the task force struggled with and the reason they focused on these concrete recommendations for example calling on cms, the model, not to scale hennepin to model and hennepinlike examples so that we can in a deliberate fashion uncover this Common Element that needs to be there and the models that can be tested and proved. We can scale in a way it is almost as if hennepin is priming the pump, giving us a little bit of an example. What are the mechanisms and tools that we have for access like, for example, innovation grant awards etc. , that can help us responsibly understand the attributes of a new model moving forward . I want to get to our audience questions. If anybody has a burning additional comment about the conversation we have been having yes. Only to mention that in passing that a previous study would put out a year ago called training doctors were preventionoriented care, we havent talked about that too much either, but it was headed by dan glickman and donna shalala. Jeffrey when bill mentions how you create trust, i think that is part of it could recognize that people in the community are their partners and that is rePublic Health could be an twopiece. An important piece. The clinician that is told that there is these Wonderful Community programs and you will have much Better Outcomes cms is holding me accountable for reducing calls among the elderly. How do i find those programs and feel confident in referring my patient . In massachusetts, the Health Department has developed a database that is integrated with Electronic Health records and makes those referrals to communitybased organizations and the communitybased organizations report back to the primary care provider. There is information going in both directions. Just as importantly, the clinician can feel confident because theres the thirdparty validator of the programs. But it is as appointed to mention that there is almost as much mistrust from the Public Health site as there is from the clinical side. Lisel if you could identify yourself and ask your question could you pass the microphone . Thank you. Is that on . I am any violation scientist an evaluation scientist and register owners of some 25 years. Worked a great deal of my time in home care but also worked inside hospitals. Recently i attended a meeting held in the National Quality forum where a representative asked a question that i initially thought was rather poignant and in some ways kind of wrong. But as i think about it, it makes sense. Its all of this prevention works, and it should, how are we going to keep our hospitals full was the question. Now, it is a bad question, but if you think about it, the question underlying it is how do we keep these people employed, and what do we do with the Cost Shifting that is going to happen because of prevention . Basically, how can i work myself out of a job and yet still going . Lisel alice . Alice thats a good question, but i dont think the answer is really as hard as it sounds. The answer to how are we going to keep all hospitals open is we are not. We are going to convert some hospitals or hospital wings or whatever as has already happened, as you know, to Outpatient Care and possibly other things that have to do with prevention. And so what are we going to do with the building is not so hard. It really is difficult to get hospital administrators to say that you are telling me that i ought to encourage things that give me fewer patients in my hospital. It is going to be a long road to helping them see they could reside over preside over a different and more varied enterprise, but it wasnt going to look exactly like the hospital that they have known and loved. But one of the things that helps answer the question what are we going to do to Keep Health Care workers employed is we are in a situation in which no matter how much prevention we do, we are going to need more health care because of the demographics because we have this bulge of older people and older people are sick or sicker, even into good prevention. I dont think the question of are we going to have unemployed pediatric cardiologists is a very serious one. We are going to have to retrain some people and train new people in the skills of prevention. This is disruptive on the Public Health care side. It is not like theres not enough work to go around, but the nature of the work that everyone is going to do, 10, 15 years from now, someone else in here will be observing the nature of the change not just on health care side but the Public Health side, in terms of who does what and how. Washington journal darshak one interesting model maryland is doing this right now. Hospitals have these fixed total costs. It is complicated as all these things are, but the bottom line is this you at the hospital cannot make a lot more money by just doing work anymore. You have fixed budget. Suddenly, think about the incentive. You euros to you used to go to the hospital and, oh emergency wait time is five minutes. Come on in. Now when you have a fixed budget it is totally different. They are like, we dont want to see you again. You have a situation and suddenly hospitals are investing in Mental Health clinics in their communities. They even themselves have the market incentive to do exactly what it is you are doing, and i think this model, it is come again, complicated should we are evaluating it, there are all these issues. But this we are trying to replicate this if other states are interested as well. These are the kinds of steps we are taking to address this kind of problem. We want to market, where possible, to take care of these local needs and not have us impose it from the outside. I would like to address something there are some biases excuse me . Oh i am alan ross and ive done quite a bit of Public Health work in my professional career. There are some biases that exist in terms of prevention on substances that could have a very big impact on prevention, but the biases have put these down. I bring up one, which is vitamin c. People will tell you, oh, that was line is calling and that is in disparate that was Linus Pauling and he has been disproved, that is not the direction to go. This will be a surprise to many of you George WashingtonUniversity Medical center has a vitamin c clinic. They will tell you a lot about the science of items the of vitamin c, and why we should look at it. Take another one from a powerful steroid hormone for which there are 35,000 Journal Articles, enough rtcs were there too randomized controlled trials, and yet this substance vitamin d is not talked about much in terms of real prevention, when the sun could give us a lot of help and that. But then the dermatologists have given us the story that we shouldnt have this exposure. And a lot of Health Problems have resulted from that. Sure, you want only reasonable exposure. But we want the information getting out to the public. Things like this, where biases have crept in, the science has to be examined and understood deeply. There are those who know the science, vitamin d at boston University Medical center, when to them lisel thank you. Can anyone address this area, and have you thought about it . Jeffrey there is never going to be definitive answers on a lot of questions, and our answers on nutrition are shifting over time. I think the right policies are made based on the weight of the evidence and institutions like the institute of medicine bring people together to make those judgments. As with anything we do in medicine and Public Health, we go on the basis of the best knowledge we have at this time, with the technology and as new data become available, we make changes. Lisel bill . William h. alice and i were on a conference yesterday and brought up something called the white hat analysis, which comes from peerreviewed articles. There may be bias in those articles because the editor has a certain bias. The point i recently make here is we have problem we probably need to go outside for the discussion for hard evidence from other sources besides Peer Reviewed academic articles for determination of what should be pursued in terms of our analyses. Lisel question in the second row. Oh sorry. My name is mike and im with the National Organization of integrative physicians who are trained in prevention and wellness. And i guess my question is primarily for lisel perhaps. I was here about nine or 10 months ago, and i believe there is another task force, and the staff director, and want to say them is janet im not certain. My memory plays tricks sometimes. It is not wellness so much as memory retention for me. But that task force is an employer task force. There is a representative who is the chairman of edna, and verizo chairman of aetna verizon is represented, and cocacola, among other groups. When you talk about Community Support and Community Prevention and a Data Collection and Data Tracking is there a synergy between these groups . You guys talk have you guys talked