Challenges for American Health care. This is about 90 minutes. Thank you all for coming back after the break. Appreciate it. Hi. Im david im the ceo of specific Business Group on health. First i want to thank them for sponsoring this meeting for us. It is across many points of view they have a strong stake for their own populations and for everybody in the country. Its important to note that while these are tremendous organizations that are investing a great deal in experimentation and learning they are not typical of american employers. Any small and medium sized employees around the country to influence health care. I think one thing well talk about is the implications for these kinds of strategies for other employers who have the same resources to effect the market. We think theres a lot to be learned. What i want to do is take a minute to transition between the first panel and the second and mention a few of the themes i think we have heard. We talk about implications for the market as a whole. First there are lessons. Most of the topics you have heard described today have a mirror image. So we do want to be learning and have a dialogue between thought leaders and people here who are developing much broader Public Policy statements. What the employers seem to have learned is they have to be thoughtful in crafting the en e environments which they are crafting. They are engaging in direct discussions. They are not relying only on their health plan as a mediating organization but they are critical as everyone said but they find themselves needing to drive with the providers. Moreover they remain in direct conversation with their provider systems. If you get into the weeds of some of the models you have heard about today youll see how much energy they are putting into understanding the care paths and trying to support them in making necessary changes. Implication of that is something we are thinking about as a group. We all talked about Insurance Coverage and insurance products. What we are hearing is what needs to be done and that means a reallocation of roles for everybody in the system which we have to see more about so the signal to the Provider Community and the public is very important. We need a dialogue between Public Policymakers and private employers about what that is and how it can be reenforced by everybodys behavior and action. I also took away observations. First of all their concerns are the same as we hear in state houses and hear in congress. They are acting on the same concerns, same costs and same variation issues. They are often using same approaches as we mentioned. And make things happen in our economy and of the world. That is first problem solved. Cost solutions will follow quality solutions. We all agreed we will have to measure that quality and design programs and improve that quality in an accountable way. They are deeply invested in understanding their work force, Provider Community and impact of the health care they are arranging on their work force. This is not a superficial engagement. There are some differences, things they can do and dont do that dont apply as much as Public Policy. You heard their work force can be concentrated and can be rural and can be urban. An organization like medicare that they dont have as much ability to tailor and flex. As we think about changes in Health Policy well need to think more about how to allow for appropriate. They have very different case makes. So those are some of the broad things we heard. We will talk about the implications we have seen in the activities of Public Policy development coming forward. Ill invite them to take it from here. We will confuse because we on the part the washington outlook, at least many of us do. With that let me make a few comments not stonding there davids comments were an excellent hand off for this panel but he didnt mention medicaid. There is a tendency, i think i certainly have it, to think about medicare and then sort of, medicaid is kind of tough because the states run this. There is a growing appreciation that the employers we heard from this morning clearly recognized if you dont Pay Attention to the client population, if you dont understand something about the Delivery System in the local area rather than some generalized sense youll probably have trouble implementing cost saving value and changes in policy. So i think its a real possibility that part as further reforms. We are just going to call it by different names and its going to continue on forever, which is, i think good for this panel. If it were not the case we would all have to find other jobs. I think part of the future of Health Care Reform is reader appreciation for the rural states. So i think thats something that we may well see perhaps later this year. Let me introduce the panel. Im going to introduce people in order of speaking. First we have lynn nicoles. Lets see. I have to find me lynn is a distinguished two pro feser for Health Policy research and ethics next we have clay who is principal and is actually a great deal of experience with Prescription Drug business fda regulation and so on. He spent earlier times up on the hill and so he knows where some of the bodies are buried. Then karen fisher, karen is now at the association of american medical colleges. But before that many years working on legislation for the Senate Finance committee and other roles. Fin finally ovick. It is a great new effort called the foundation for research for equal opportunity. It is not just narrowly focused on health issues. Ovick as many of you have seen him on tv is a true Health Policy expert. With that why dont we start with lynn. Well argue with each other until you stop us. Thanks, joe. Joe gave us five minutes. So i will try to make three points. You can use ten. No. No. No. I will stick to five. Thats fair. So i have three points. Two about whats going on now and one i think we need to think about going forward. First i want to begin about how happy i was to hear him say the word bipartisan seven times. Every single paul ryan budget, go back and look at every single one of them, including all of the medicare payment stuff. The most comprehensive produced before the election, he is a longtime collaborator who always wrote the defensible way to think about this right on the hill. Hatch is chairman of finance. That bill includes all of medica medicare. As congressman laid out it passed with just about the largest bipartisan majority since world war ii. That is a very very good start. The second point i want to make is this Public Private cooperation that has been waxing and waning and going on is a twoway street. I think you can see a lot of good features that are coming out of that. First and one of the things i liked best about the way the invasion center did its business was emphasizing multipayer mi h initiatives. The reason it matters is basically to get the incentives and reporting requirements aligned between payers so that they can focus on what they went to medical school or Nursing School for. I know where i now have the pref l privilege of living. They are recording between 240 and 500 different quality different quality me tricks. I dont know what the right number is but it aint 240. I can assure you that. We have got to do a better job. The only way to do that is get that going on. There are lessons that i think you can learn from some of the different similar but differently structured activities. It is the core of making it work. It is the core of making our Health Care System more patient centered. Thats the idea. Its been tested in lots of different ways. One of the largest public tests was the comprehensive primary care initiative. I dont recommend you read it in one day but i recommend you take a look at it. It basically found, drum roll, no cost savings. The only part in the country that saved serious money was oklahoma. Oklahoma has a really well functioning and Health Department information which takes data and combines all of the pairs and all of the ehrs. They did better. Saved money in year one but not in year two and three. It did not overcome the cost associated with the rather i would even say very demanding requirements of the government in all of the things they wanted the primary care docs to do. Contrast that with the patients private sector i know a fair bit about it because i have been evaluating it. It is maryland, d. C. And northern virginia. Unlike the government approach they didnt dictate a whole bunch of things. They wanted you to do 24 7 access, same day appointment. Pay attention and focus on care plans agreed to by the nurse manager and the patient, sign the contract then go forth and prosper by focusing on those people. They saved about 2. 8 or maybe 3 in years two and three. The larger point is this, kind of like what i heard our employers say. They dont really want to get into the micro managing business of how to do it but they want to set the right financial incentives so the docs can do it. Maybe an important lesson is instead of getting a bunch of experts in a room and saying this is what we think doc should be doing, maybe what we should be doing is focusing on which patients to focus on. That is a very very very important thing. The evidence is the date that predicts which [ inaudible question ] [ inaudible ]. The secret of health care which is surprising. That is market power on the part of survivors. As big as walmart is it cant really tell local hospitals what to do. Boeing is in a little bit different place in about three places. You can do it, sort of kind of. So no employer has enough market share to drive it. Its a better way that we know congressman ryan and others will push pretty hard. Okay. Fine. Thats done. Let me point out and read that thing closely. Its all about turning medicare other to health plans, which sounds clean and nice and simple. Here is the thing, they dont have market power either over a whole bunch of hospitals. If you got it out and turned it over and said good luke. I dont have to worry about it because i dont have to worry about it you will care pretty qui quickly but we need all of the buyers to be focused on exactly how to move to the promise land. Lets talk about the promise land. One really great feature of being tenured is you have time to read stuff that you wouldnt have time to do if you werent. I will tell you three things you should read too, but not in one day. The Inspector General of hhs, you may think what do they have to do with anything . They do sort of evaluations from their own legal point of view of implementation. They just released a report of implementation of Quality Payment Program which is a big part. It is about the physician reporting stuff. You will see pretty clear recommendation for back office i. T. , which is sort of, you know, euphemistic speech for figuring out how to get the data out in such a way that we can actually do what we said we were trying to do in the regulation which you heard congressmans praise. Okay. Thats point one. Point two, read that third year evaluation and you will see even where we are spending 18 bucks for three years you have got places in this country where the docs cant get out what everybody agrees should be measured. And the third little piece is a project that im involved in which is funded by the basic idea to try to enable small practices around the country to be able to help manage patients with heart conditions much better for all of the usual reasons. I signed on and i was told by the pi of the project, dont worry. You just need to work on the statistics. Oh my. I have had to learn way more than i ever wanted to know about getting data out and about the fundamental inability to function the way they were promised. So now i will bring you back. What we are doing in this regulation is we are saying 90 of what youre going to be judged on in the first year comes from either your ehr. 10 of it comes from claims which medicare will tell you what your total cost is. I submit the you those percentages should be first. We should figure out how to get the data out. They should not be required to have to produce these on their own. We dont want them to learn. We want to enable them to participate in an infrastructure where they can bring two clinical Decision Making all of the data they need in realtime and it can be done because oklahoma proved it can be done. We need to think about how to build that i. T. Backbone so that doctors can actually participate in the 21st century. Let me tell you whats going to happen if we dont. These little practices which are still the core of our nation are not going to be able to compete. They put four to 9 within three years of total medicare revenue at risk and its total zero. Youll lose if youre at the bottom of this pile. They cannot win because they cannot make them generate to tell them how to do better. We have to do this for them. It can be done cheaper. It will have to be an infrastructure kind of investment. Ill stop. Thank you. Glenns talk reminds us all that in washington we have a different standard of measurement. So if that was five minutes, well [ laughter ] bill clinton time. [ laughter ] clay, take it away. First i want to say thank you so much for the opportunity to be here today and to speak. I want to echo, i learned a ton from all of the speakers this morning. Thank you for those contributions. What i would like to talk about today is the uncertainty here in washington. It has been what we have all been facing since the election and uncertainty about everybody that had a memo and had to rip it up and recalculate on every single issue across the health care landscape. So there were a lot of predictions around that. So what we do in washington really well is ill make predictions. It is why i think they are sound. It is where some of the things that may progress. It will be a very busy year across the Health Care Sector here in washington. Everybody will be implicated in the discussion. One thing that i think youll find is a bipartisan idea and it will be throughout what happens. What i would like to do is walk you through three different settings. Congress and the private sector about some of the ideas from the first panel, will they present themselves that we are going to have . First we have congress. I think i walked a lot with dr. Burr guess. He did a tremendous job of walking through what you can expect from his committee. Thats where i did my work. They will have a full plate. But the predominant what we are going to hear is about repeal and replace. It will take all of the oxygen out of the room. It will be where all of the activity from the policymaker standpoint is going to be centered. When you look at repeal and replace and i echo that it was definitely welcomed news. I think when you look at repeal and replace one of the questions that gets asked and should be asked is whats involved in that . What are you going to see in this piece of legislation . With repeal and replace and what republicans have been talking about since the passage of the Affordable Care act is a need to reduce costs for consumers. It has been one of the main arguments. You have your policy debate. It is reducing cost for consumers. It will be a focal point that they want to put forward to try to accomplish that. So the better way that dr. Burr g burrgess talked about, they both have one key component and that is Health Savings accounts. Health savings accounts is something the republicans have been talking about for a long time in policy circles. And i think that is an idea you heard a lot about really well in the first panel. What they are going to look to do is find ways to foster the continued expansion and continued you know, make it easier for folks for veterans or others to continue with Health Savings accounts. So that will be one important feature. A second part of it and youre going to hear a lot about repeal and replace and whats going to be in repeal and replace. I think joe said it really well that a lot of focus has been about medicare. Obviously medicaid has a big part of that as well. I think what youll see in repeal and replace is there will be a lot on what can happen to make that work and what can happen to consumers. There will be a lot of talk about medicaid and what the future of medicaid will be and how that will move forward. Medicare, it will be part of the debate as part of repeal and replace. Its not likely to be a prominent feature. It is not a big part of it. It is what you have heard from senator alexander. It is as much as it is a huge issue on the republican side. It wont be part of it. It will be part of the congressional debate though. What i would say is fiscal year 2018 budget, right now it is around the 2017 budget. Thats what is going to give the reconciliation to begin that process of repeal and replace. There is actually a vote that will happen today that will approve the reconciliation instructions and that process will basically start. So phase 2 will start. It is a little odd to pass the budget after youre already in the period. Youre already spending the money but its not necessary to move the reconciliation for republicans. For fiscal year 2018 i talk about the policy debate. There is going to be a real sense among the republicans in congress and from the administration to try to find some fiscal order that around spending that were part of it the why that budget wasnt passed and in this budget as you look at it what we are seeing from the federal standpoint is that mandatory programs are crowding out discretionary programs. So when you look at the caps that are a part of the federal standpoint the discretionary caps, whether its the Defense Department or its for how much you know, for health care or how much more money there will be for nih, all of this is centered. The issue that has been here and will continue to be a problem according to the republicans unless it is solved is that the mandatory programs, medicare and medicaid are crowding out the rest of the bujd and there needs to be some kind of, you know, order brought to that in order for the federal budget to actually work. That will b