Thank you all for coming back after the break and finding a seat. Appreciate it. Well just get settled again. Hi, im david lanski. Im the ceo of Pacific Business group on health. Some of the panelist you just heard from were members of ours. Let me just say a word about what were doing here and my job here really is to help make a transition between the wonderful case studies and purchasers to the implications for policy development in washington where we started the day with dr. Burgess. First i want to thank aei and brookings for sponsoring this meeting with us. Tremendous opportunity to have a dialogue that is nonpartisan and across many points of view to try to think what the successful developments of health care policy. Pbj is one of the sponsors. We represent about 60 very large employers and purchasers. They together have about 12 million covered lives and together they spend about 60 billion every year so they have a strong stake in the improvement of the Health Care System for their own populations and as several Panel Members said for everybody in the country. Its important to note that while these are tremendous organizations that are investing a great deal in innovation, experimentation and learning, they are not typical of american employers and there are many small and medium sized employers around the country who dont have the resources or the scale to influence health care as directly as some of these companies can so i think one thing well talk about today is the implications for these kind of strategies for others employers that have the same challenges but not the same resources. We think theres a lot to be learned of the lessons of the work we have done. I want to take a point in transition between the first panel and the second. And for Public Policy development. First, there are lessons. Most of the topics you heard described today have a mirror image in Public Policy. In aco development, in hsa design and so on. So we do want to be learning actively and have a dialogue between these thought leaders and innovators and people here who are developing much broader Public Policy statements. Id also note i think this was highlighted in allisons questions. These are carefully constructed programs. These are not blunt instruments. What the employers have learned often, they have to be thoughtful in crafting these programs to suit the need of their population and the environment. Secondly, these employers are engaging in direct discussions with providers. They are not relying only on their health plan as a mediating organization. The health plans are critical, as everyone on the panel said. But they often find themselves needing to drive innovation directly in conversation with the providers. And then moreover as you also heard, they remain in direct conversation with their provider systems. If you get into the weeds of some of the models you heard about today youll see how much time they put into understanding the care paths, and trying to support them in making necessary changes. Implication of that is something worth thinking about as a group. Weve all talked a lot about Insurance Products and insurance coverage. A lot needs to be done in actually redesigning the Delivery System and that means a reallocation of roles for everybody in the system which we have to think some more about and certainly Public Policy is critical. The third broad point is the alignment is becoming critical. Any one of these companies i think as sally said as big as they are doesnt really influence all the dynamics of the Provider Community or the marketplace. So that having alignment of signal to the Provider Community and to the public is very important and we need a dialogue between Public Policy makers and private employers about what that signal is and how it can best be reinforced by everybodys behavior and action. I also took away some observations about the employers. First of all, their concerns are the same as the concerns we hear in state houses and congress. They are acting on the same concerns, the same costs, the same quality issues, the same variation issues in trying to find the tool kit to address those concerns. Theyre often using some of the same approaches as i mentioned. Very strong in todays discussion that quality comes first for them. Ultimately their biggest cost and biggest concern is having healthy products. 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. Its a deep analytic engagement and theres a lot to be learned from the analysis they have conducted. There are some differences, things they can do that dont apply as much to Public Policy. Their work force can be concentrated, spread out, can be rural, can be urban. They had to select and design programs they can manage within the constraints of their particular business arrangements. An organization like medicare operates at a national level, there are pressures to act in a uniform manner across the country. 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 flexibility and socially desirable uniformity. They have very different case mix. Some have younger employees, older employees, industrial employees, longer tenured employees, brief employees. Others dont have to think in those terms. I think the last issue is to think more together about the relationship to providers as distinct from the relationship in the insurance product. Macra is an opportunity for us to think in new ways about how to trigger value in the activities of the Provider Community. So those are some of the broad themes ive heard. Now we will bring up people who understand policy far better than i to talk about the implications of the lessons we have seen from the private sector in the activities of Public Policy development coming forward. Joe will introduce that panel and i will invite them to come up now and take it from here. Thank you, david. Do we understand policy better . Well, we have probably been burned more by it than the employers. Its a big challenge. It was a great first panel and now we will attempt to obfuscate and confuse, because of course, we represent the washington outlook, at least many of us do. With that let me make a few comments not standing there. Davids comments really were an excellent handoff for this panel, but he didnt mention medicaid. There is a tendency, i think i certainly have it, to think first about medicare and then sort of medicaid is kind of tough because the states actually run medicaid and no matter what cms thinks. But i think theres a growing appreciation that certainly the employers that we heard from this morning clearly recognize that if you dont Pay Attention to the client population, if you dont understand something about the Delivery System in the local area rather than in some generalized sense youll probably have trouble implementing cost saving value producing changes in policy or in the way you run your system. So i think its a real possibility that as part of further reforms, Health Reform is never going to stop. 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 Reform is greater appreciation for the role of states. So i think thats something that we may see perhaps in a repeal and replace bill later this year. Let me introduce the panel. Im going to introduce people in order of speaking. First we have lynn nichols. Lets see. I have to find my have to know what year your title is. Lynn is a distinguished professor and director of the center for Health Policy research and ethics at the edwards mason university, a washington person. I think you got your start in the Clinton Administration working on Health Reform and youre still working on Health Reform. Hows that working out for you . I know its going great. You win some, you lose some. Next we have clay alspach, principal at levitt partners, and has 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. And then finally, avik roy. Avik has had an interesting career. I have known him for quite some time now. Hes moved around a lot but hes started a new think tank. I dont want to think hes trying to be competitive with aei. Who could compete with aei . Exactly. Its a great new effort called the foundation for research on equal opportunity. It is not just narrowly focused on health issues. Avik, as many of you have seen him on tv over many, many years, is a true Health Policy expert. With that why dont we start with len. Well go down the row and then 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 basically 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 by saying how happy i was to hear congressman burgess say the word bipartisan seven times. I counted. You should tweet that. This is important. But seriously, that is serious, but second, it is a very serious point to say that there is truly bipartisan support for the value agenda. Every single paul ryan budget, go back and look at every single one of them, included all the medicare payment stuff thats in the aca. The merr hatch upton, in my view, the most comprehensive congressional alternative to the aca produced before the election, burr of course is chairman not chairman, but longtime collaborator with tom coburn, who always wrote the intellectually defensible way to think about this from the right on the hill, coburn retired so burr took up the crucible. Hatch is chairman of finance. Upton is the chair of energy and commerce. These are very important people. Hatch will be extremely important in the end game. That bill includes all the medicare payment stuff. Of course, as congressman burgess laid out, macra passed with just about the largest bipartisan majority since i dont know, world war ii. It was pretty overwhelming. So that is baked into the system. 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 Innovation Center did its business pursuant to the aca was emphasizing multipayer payment initiatives. The reason multipayer payment initiatives matters is basically to try to get the incentives and reporting requirements and all the information flows aligned between payers so that clinicians can focus on what they went to medical school or Nursing School for. I know of Hospital Systems that are now participating in a whole bunch of things and they are reporting between 240 and 500 different clinical Quality Metrics. As a simple Country Health economist i dont know what the right number of clinical Quality Metrics to report is, but it aint 240, i can assure you of that. We got to do a better job. The only way to do that is get multipayer framework going. I applaud the participating plans and employers who have done this sort of thing. There are lessons that i think you can learn from some of the different similar but differently structured activities. My favorite is patient centered medical home, a, because its the core of making an acl work, the core of making our Health Care System more humane and patientcentered. Thats the idea. Its been tested in lots of different ways. One of the largest public tests of the model was the comprehensive primary care initiative. The third year evaluation by mathematica just came out. 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 over three years. The only part in the country that saved serious money was oklahoma. You might ask yourself how the hell did that happen. The answer is because oklahoma actually has a really well functioning Health Insurance exchange, Health Information exchange which takes data from the docs and gives them back actionable reports in realtime, combines all the payers and all the ehrs into a setting and allows socalled big data to actually be analytically operational for clinicians on the ground. They did better saved money in year one but not in year two and three. In general the program did not overcome the cost associated with the rather, in fact, i would even say very demanding requirements of the government in all the things they wanted the primary care docs to do. While they gave them 16, 18 per member per month, they spent it all doing all this stuff. Contrast that with the patient centered in the private center. I know a fair bit about it because i have been evaluating it. It is designed by care first midatlantic. Which is maryland, d. C. , and virginia. Unlike the government approach they didnt dictate a whole bunch of things you had to do. They wanted you to do 24 7 access, same day appointment. Pay attention to the data we give you and focus on care plans, agreed to simultaneously by the doc, by the nurse manager and the patient, sign the contract and go forth and prosper by focusing on those people. They saved about 2. 8 or maybe 3 in years two and three. The evaluation is ongoing. 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 and information flow so that the docs can do it. What i would observe is maybe an important lesson here. Instead of getting a whole bunch of experts, fun though we may be for retreats, in a room and saying this is what we think docs should be doing, maybe what we should be doing is focusing on which patients to focus on. Because that is a very, very, very important thing. Youre not going to save money on every patient. I dont care what you do. You are only going to save money on a particular subset of patients. There are a lot of ways to think about how to identify them and a lot of advance in socalled Predictive Modeling coming out of claims based and clinical based data in my opinion. The evidence, this is where oklahoma comes back, the evidence is the data that do best are those that combine clinical and data to predict which patients to focus on. So let me set that up. The third lesson that i would say or the third dimension of this Public Private twoway street learning experience as its going on is the dirty little secret of health care which no one mentioned today which is kind of surprising, although sally sort of alluded to it for a moment. That is market power at the local level on the part of providers. As big as walmart is it cant really tell local hospitals what the hell to do. Boeing is in a little bit different place in about three places. You can do it, sorta kinda. But really, its a p. R. Game youre playing that they want to play with boeing. No big employer has enough market share to drive it. Lets segue to a better way that we know congressman ryan and others are going to push pretty hard. You heard burgess had already signed on. Okay, fine, i guess thats done. Let me point out and read that thing closely. Its all about turning medicare over to health plans, which sounds clean and nice and simple. But heres the thing. Health plans dont have market power, either, over a whole bunch of hospitals. So if you got medicare out of the fee for Service Business and turned it over to health plans and said good luck and now i dont have to worry about it because im going to give you 5 a year and i dont care, you will care pretty quickly because health plans are not able to drive the kind of bargain you really want, nor are employers able to drive it. We need all the buyers to be focused on exactly how to move to the promised land. Lets talk about the promised land. Thats my third point. 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 analyses, kinda, sorta evaluations, if you will, from their own legal point of view, of implementation. They are looking, they just released a report on the implementation of the Quality Payment Program which is a big part of this. It is about the physician reporting stuff. You look in that report, 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 of the ehrs in such a way that we can actually do what we said we were trying to do in the legislation and in the regulation, which you heard congressman burgess praise. Heres the little okay. Thats point one.