I think you pretty much took my entire speech when he mentioned the word cbo. Unfortunately, i think it is, i think this is something both sides of the aisle, this is something bipartisan we kind of struggled with right now is we are kind of living in an arrow cliff. It is one cliff after the other after the other. The debt ceiling or the sequester or the sgr cliff. Does congressional staffers, im sure debbie can attest to, we are constantly living in his temporary environment because we have to. That is unfortunate your we would all like to take some time and do a deep dive into deep policy thinking and try to think of transformational ideas that can transform everything, but when we kind of walking to work reality hits us. We have a job to do. We have to take of the thing that is the most pressing on the front end, and, unfortunately, thats kind of the environment we are living in. And it was a very interesting panel, especially the last one, where i was hearing, theres Nothing Better than congressional staffers. Actually talk to patients are going through the clinic. One of the things that, the reality that we suffer with, unfortunately and this is something we all have to deal with come is just the fiscal reality. As you rightly pointed out, it is right now the debate is about budget and at, people are cant figure out to control costs but also how to find actual savings that are scored by cbo. The Congressional Budget Office gets a bad rap from a lot of people, but im a fan to have a very tough job to do. They always come out with answers that doesnt please one side or the other side, but trust me its a very tough job that they have have had to do, and its hard to please everyone in a town like washington, d. C. They try to do the best they can. I of fort a lot of respect to them. But at the end of the day thats the reality we have to operate under. So we get a lot of ideas. For example, from my great state of utah which might cost represents we have a Great Health Care system which is on the periphery a lot of the integrated Health Care Delivery reforms, and some of the most Amazing Things that are being done. Ordinations i. So we are very lucky to kind of have this working model in the state we are from, and they have great lessons for us but a lot of time those lessons, as much as we would like them too, dont really translate into real cost savings. So when that doesnt happen with enough to kind of move onto an exercise where we can actually realize some cost savings. The last thing i will say is, we are now in an environment that all of the lowhanging fruit is gone, just being completely candid. People hate to hear that and people like to say the best thing you can do and that you can do, well, i completely appreciate those thoughts that we do live in a fiscal reality that is governed by agencies like cbo. We have to look at ideas that are scorable. And at this point once again i can only speak for my office and my boss, we are much more deeply engaged on entitlement reform side because we do believe that the end of the day if you really want to put an actual consistent downward pressure on health care cost, the way to do it is by reforming our entitlement system. And Health Care Delivery reform is part of it but its a twopart solution. Its not just a focus on one to make a look at the other because its more tough to do at a later date. I think the time has now come to kind of swallow the tough medicine and start addressing both of these ideas together. From the other side of the aisle. I associate myself with most of the remarks had been said today. This is been an interesting panel. Its a discussion wed have a lot more. I would start off by saying that we have, i think theres some consensus the status quo a across health care isnt sustainable but i would also but i dont we are a self selecting group and we are chosen to involved in this. And involved in things or and washington to try to do and around the country to try to change the system. Rochester, for every rochester there is a texas where they are fighting change every single day and making a lot of money in the process. So weve got to figure out a way where we can get this conversation much more out across the country, and to the single practicing physicians who dont want to change. I guess my next thing is over all that changes hard. When youve been doing something, just think about ourselves, when my Computer System changes at work i freak out for a couple of weeks. To try to think about how you change incentives for physicians and change the way we deliver care to drive value is a much, much harder thing to think about. We do have great private sector examples. The gentleman earlier, what are not financial incentives, look at kaiser. Cash is a program where doctors get paid less than they would if the feeforservice medicine that people flock to kaiser because of the quality of life and people go to medical school not to deal with insurance company, and all the different paperwork. They go to practice medicine. Kaiser come you practice medicine. Its a collaborative system and there are lots of other examples like that that are growing around the country. So i think theyre a tremendous nonfinancial incentives that we can provide to the vision but we have to figure out how to incorporate them into the system. I guess my broadbrush kind of statement, everyone has had their one little statement on these panels, and mine is first, harmed. What i see upcoming in this debate about entitlement reform, which i would argument that so much be about reform, is that weve got a situation where we passed the aca, everyone can say nice things are complained but what that will has done is build a process. Cmmi and other demonstrations that are built into the system to test new Delivery Systems, and to figure out if they work and really build a model where they can go forward without congress having to interfere again. And that is a really important thing, but if congress decides we need to get 400 billion, 600 billion, 372 billion, these random made up numbers that we have to pull out of the medicare system, i just remind everybody that we did that in the aca. Simultaneously republicans ran campaigns for Congress Thing you cut 716 billion out of medicare, you are horrible. Then they say we need to cut another 600 billion. It does not frankly make sense. So i think weve got to be very careful on the medicare side that we dont poll so much out, that we in danger the ability of all this innovation to move forward. And we endanger the ability of doctors to remain engaged in the Medicare Program, and that goes to needing to find a solution to the sgr, which again i agree, i care members, we need to build a the consensus that most people the new systems. But you cant as long as we continue to of the cliff of sgr out there, the other cliff, then were not able to think longterm care and do the things that we need to do in the Medicare Program and across her Health Care System to innovate. So i guess my number one thing is lets look at the facts. Because of the aca and other changes that are going on, the economy has some to do with it, weve lowered the growth rate in medicare below cpi. That has never happened. We have really lowered the growth of medicare. And in doing that we are creating tremendous savings for the government, but we are not hurting access to care right now. We need to preserve that. If we achieve greater savings on paper out of the medicare system, but destroy that system for people, that is not an outcome that is a good outcome for our country. And i think is much private Sector Innovation as there is an continue to be, lets be honest but if the private sector can do this, we have a functioning Health Care System outside medicare, and we dont. And we do because it takes all of us working together. Most Insurance Companies today use Payment Systems which was developed through the Medicare Program with government. Weve got to figure out how we can continue to collaboratively work, and hopefully take politics out of some of what medicare has become an move forward in a way that really improves our Health Care System. Dana safran, you represent the other unrepresented elephant in the room, the insurance perspective. Any immediate thoughts come to your mind . Yes. Its been a really interesting and exciting morning from my perspective, from the first panel, deep thinkers, two who were as all observed enormously a line in the vision of what needs to happen. Moved to the second panel of ill call them the deep of doctors, who also were enormously outlined in what needs to happen. So i feel like part of my role here is to inject some optimism that actually these things are happening. These are not just deep thought toward the possibilities. And so if i could take just a few minutes to share how this actually has unfolded in reality in massachusetts, over the last several years. And really the images for this was that in 2007, as folks in this room probably know, we began implementing our state law to extend coverage to everyone in massachusetts. And have succeeded at covering their everyone in massachusetts, but the next mountain to climb was quickly apparent to us. In the early months of 2007 we knew that we had to reform payment and that that payment reform had to deliver the kind of Delivery System reforms that would produce longterm sustainability in spending growth, and at the same time and improve quality. So those twin goals, holy grails, can you really reduce medical spending growth and improve quality and outcomes was the mountain we felt we had to climb in 2007. And so the company i work for, Blue Cross Blue Shield of massachusetts, begin developing a payment model that by the way we made completely voluntary. So this was not a forced march into a system, but something that back in 2007 when no one was talking a payment reform was out of their an optional model for providers organizations that felt outlined that we could do better, and that we needed to do better because of the cost prices that were surely coming. Now that we would have the universal coverage. And really there are four things that are distinct about that model. We talked about pretty much all of them this money. The first is the Provider Organization that comes into the model takes accountability for care across the continuum for their Patient Population. So everything from prenatal care and endoflife care and everything in between is their responsibility, regardless of whether they personally deliver the care or it happens elsewhere in the system. Thats very different mindset, and leads to very different behaviors and relationships and staffing models. From a model that says youre only responsible for the patient who was in front of you this moment, that you will build for and then they will be on their way. So creating that kind of longitudinal accountability is one very important difference of the model. A second very important difference of the model is that its based on a global budget for the population. And to our shared savings and theres also risks. There are all kinds of protections so that that is a Reasonable Risk and the budgets are set anyway that is accounting for that Patient Population and whats been spent to take care of them up to that point under feeforservice model. So that the provider begins knowing that theyve all the resources that they have a day before, but now they have an incentive to try to figure out where was their wasteful spending. And i can tell you that over the four years that the model has been in place now, every organization that has come into this has found significant savings. And also made significant improvements in quality and outcomes. These have been documented in new england journal of medicine, health affairs. This is not just our say so. And thats our network has seen these successes, and also heard the drum beat that maybe now sounds like payment reform is coming, there has been faster adoption of the model to where we now have 80 of our Provider Network contracted in this way. Taking accountability for total medical expenses and for quality and now, being rewarded very significantly for achieving better quality and Better Health in the population that they take care. A third thing thats different about the model is that its a longterm contract and the rate of increase over that longterm is negotiated up front and comes down to look like general inflation by the end of the model. Back in 2007 when we were staring at this problem of trends that were 11 , 12 , double digits every year, we knew we had to cut at least in half and thats happened. The economy also contributed to that the part of what is built into the contract is even as the economy rebounds, the contracts are scheduled to grow at a rate that will not so far outpace the rest of the economy, that it continues to be an affordable system to the final piece that is distinct is that we the plan work in partnership with the Provider Organizations to help them be successful in this model. Because we have the data and the holistic view on their Patient Population that they dont necessarily have. And many of them, most of them have been functioning under this volumebased set of incentives that really now is 180 degrees different. So working together, best practices sharing, we are making enormous strides and we have in massachusetts a system that is looking very different. You ask where can i go for care that looks like that. Youd be hardpressed actually in our state now to go somewhere that isnt focused on care that looks and feels patients like onto your care because practice are very concerned about of windows by mr. Uses of the Emergency Department that we heard about this morning and is unnecessary admissions and read missions and the things that really add enormous expense. So im optimistic that if we can do it in one day of the country, that with the same burning platform of affordability and quality failures that exist everywhere else, this can happen, and medicare can help lead the way. So weve got lots of examples of what does work, and they are out there as a living demonstration pocket. Almost everybody agrees on almost every point. Macon, why on earth havent we moved faster to reforming our system . What is the holdup . To continue on your theme of optimism, i think there is a glimmer of hope on the way at least for congress, debbie might have some thoughts on this, but the fact that the hous house and senate are both going to write budgets for several years, and then possibly bring those budget to a conference slows down this process of the cliff coming all the time and perhaps create some room for more of the deep dive, for the Committee Said to do with health care. To deal with some of these issues that are not just raising the medicare age or of the eligibility or whatever cbo scores as a cost saver, but may believe some of the payment reforms that have been discussed up here today. You cant just get the money. You have to have the numbers to get things Pass Congress or to meet whatever number is out there. So that has been the biggest challenge and continue to be the biggest challenge. Im slightly more optimistic i guess because the process has slowed to a lived in the coming months and could set up a reconciliation process that requires less votes in the senate, makes it easier to pass more controversial legislation that made him medicare on a more sustainable path. So whats been next step in congress . Im a simple guy so i try to put a simple as i can pick plenty of people who are way, way smarter and brighter than i am, but the biggest challenge that we are facing in congress, unfortunately, is this fingerpointing exercise we always engaging. And until we stop learning how to stop pointing at and start working together is going to be very, very difficult year, if not years, to come by. And thats something thats upon my boss has made repeatedly. Theres some very tough decisions facing us. Theres some start fiscal realities facing us. So we can all eat a look at the past and to me kind of rehashed the past and keep using our same talking points, or we can try to figure out how to kind of move forward. You know, on the entitlement reform side, i understand people have concerns but that is the reality we all have to face with. Nobody has the perfect into the building is a perfect solution. But that has to be part of the solution that we are working on. We can sit here and splice the date on whats happening with health care expenditures, and you can look up the data trends and see whats happening. Again the past couple years Health Care Costs have gone down to look at 2014 and beyond and see what happens with Health Care Costs. They bounce right back at. So we can either kind of bayesian, were done our job, its time to move on, or which is okay, there are challenges that lie ahead, we all have our priorities but we have to Work Together. So lets hold hands and try to figure out a way forward. And its just, this is something once again this is something we have to do on a bipartisan basis. But when we talk simply using words like destroying medicare and those kinds of phrases, dont really help the conversation. Its much better for all of us to sit down and say okay, here are my ideas, like my boss sat down, he took an act of courage to put up by specific ideas he wanted to put out there and he said a bucolic all 100 senators and said here are ideas. Im putting specific policies on the table, come and sit down and talk to me and tell me what you like, what you dont like. That is the way were going to have a conversation, but if the conversation is going to dissolve into you guys want to destroy medicare, everything is fine, we need to do it this way, thats not good for either side and im not sayin