One thing is with all of the data that is now available for research, what we are seeing is and what is being seen by insurers, in fact that higher prices for the services does not indicate better outcomes. They are rebuilding or fixing knees and the more they do it, the more familiar with the better the out come and because they do of them. And often the price of that particular procedure is lower than it is for the guy who does one a week. If they do or two or three a day versus one a month, what we are seeing in terms of the outcomes is that often times the lower cost procedure is really producing better outcomes. The place for the network and cheaper. I think we also know that we have seen a lot of networks in the networks and the pricings are the lower in general and they expect my view that we dont know how to measure quality. A few things we do know and what i like to point out is who scores well on the care and fivestar system that is one of the systems that is leading the way on measures equality. Im not sure how well it does that, but to the extent it does, who comes highest on the achievement under that system, it tends to be the a chp companies that are the integrated System Companies like dianes company and kizer and group health. They do tend to perform better in that system. Before you jump in, you mentioned the system and the federal government is looking at new standards that are similar. Is that where we should be going . The federal government did hold up to quality initiatives for a couple of years and several different there and one of the main reasons is what they wanted to make sure that there was something else. There was a lot of work going on to align these things. I think we are primitive on being able to. I dont know if they know how to measure quality yet. I think we have a lot of work to do. Joel is right that the analogy to this discussion if you looked at the past, i think the evidence at the time suggested those plans were able to have lower cost and perform well on the stalt of the art quality measures at the time. The key phrase is at the time. The measures were not that good. The thing there is the narrowing of the networks. Not the defining feature. The narrowing of the Network Enabled them to do other things within the organizations. It will be a mistake given where we are in the process now to try to generalize about these plans. I ensure there will be exceptional ones that will provide low cost and high quality care. I am also sure there will be some that wont be as good. The challenge here is to try to set up a system that both identifies, informs, and monitors those that are falling on the part of the spectrum that we dont like. I think its going to be very challenging to try to generalize about anything about what these types of networks do. They will be local abilities to manage them well and they will have a series of other tools layers on top that will vary. You are not talking about just the network. There is a bunch of other things that occur related to the managing of the care and a bunch of other things that define the outcomes that you want. We will have to live with that and decide the extent to which we trust consumers to choose among est them and respect their choices versus limit their choices for various reasons. Okay. We are going to open up for a q ask and a. I want to remind those who are listening on the phone line or watching on cspan 2, email questions to questions all health. Org or tweet network adequacy. I want to remind everyone that we have two on the ground experts with us. We have diane holder. She is with the university of Pittsburgh Medical Center and can give us an on the ground perspective as well as alina pabin in michigan. We have on the ground expert who is will be joining in the conversation and you can direct your questions to anybody on the panel or just to the panel in general. When you ask your question, please identify yourself. I think the point is well taken with a difference depending on where they choose to go. Cutting off access to facilities is not going to work well with a consumer. If you have that treatment, it might prevent more treatment down the road. One of the things at the heart of the debate is what was adequate and you look the the outcomes and you want clinical outcomes that are an improvement in many regions and across the country. We suffer from deficits and the struggle gets to the heart of what michael said. How they get the right cost and quality. Certain minimal Access Points and it has to be balanced with both provider and insurance competition. I would add and so first let me say as i mentioned, my mother had a lymphoma and she was treated in pittsburgh and cancer is one of the most complicated areas because of this notion that you are not going to know beforehand where you go for the cancer care. When choosing a plan its unrealistic to have the Cancer Center they want. That may vary by the type of cancer. I am very, very wary of a situation in which we forced organizations to include particular providers in them because of what that would do for prices. I think and i might be wrong about this, i think that would be on the road towards some type of price regulation. To be in network is fine, but now we have to say what price you would charge. The concern is if we think there becomes a monopoly type provider. We have to think of a way to deal with that beyond a rule which is every network has to include this particular provider or type of provider. In areas that are big enough where they are competing, we might have a different approach in a place where we have different providers and all of the Network Development with regulation to make sure they have access to good cancer care and in a way that doesnt give a blank check to the organizations to say now you can charge whatever you want and do whatever you want. It is the case that they may in fact save money to make Treatment Choices and has yet to be shown that they do for a variety of reasons. Thats an academic discussion. I wanted to make the point that in and around the work we are doing, in and around the model, to michaels point, when a situation does arise where you havent decided where you want to go if something bad happens, there are formal and informal processes and i can think of one in particular where there was an informal process and they said i need to go where i can get the treatment and i need a way to get there. The long and the short of it, we made it happen and that person is alive today because of that. Thats the role of the regulator. When those situations come up. In terms of rewriting of the model, that will be filing quick appeals for emergencies and specialized care. Through formal or informal means. Consumers when faced with the challenges have an avenue to purr pursue. This seems like something they havent had in a long time to compel the hospitals in particular to do more and align their prices in response. We get a lot of hospitals who care about the Thread Counts for their bedsheets and you dont see anything reflected that gives them the ability to say wait a minute. If you want that, you can buy it. That doesnt include the fourstar hotel importance. People thought they would and to the earlier point, they voted with their feed not to. We can debate what they were over, the copanelists can demand on it and separate out the threat count from the cancer care. And i dont mean to say that, but it is a question about whether you want them to make those choices. We were having the discussions on how we create markets that work where information is not perfect and we wear about the out comes in a way that we dont for a bunch of other things. If you buy a third rate cell phone, im sorry. But bad health care, i feel differently about that. We will see and should allow consumers to make choices to get access to different facilities in the breath of their network. We have to have a lower bound and regulate the processes about that for information choice and the processes that were discussed. You mentioned that your issue is dallas is an ideal place to have these systems. There can be good competition. Some parts of the country it is one hospital. There is not the same leverage to drive price and quality. Its again another issue which you see on the pages of the press that is not connected is issues of antitrust. In combination will be aspects of consolidation. We have another briefing of how we want to allow integration. On the other hand we want competition amongst providers. Many i think are in the forefront of the minds of policy makers are overlapping. One of the themes is the extent to which we can end up with a system or competition works between assurers and providers to put that to the competition. This is where they had cms this year decided for 2015 it was going to put in place more strict Network Standards for those offered on the market places. They said they may look at time and distance requirements. What do you think about recognizing state by state differences . I love my friend, but im very leery and weary and concerned if the folks come up with a floor. I have regulators who would like a floor, but given the diversity of market places throughout the country, what i dont want to have is an extra or heavy push by the federal government to get into the business of something that states do very well. They know the market places and the distances. We do a good job. What we dont want to have is friends around here to put something in place. They are already working well. And better manage because we are right there. I would like to ask if the other panelists want to weigh in on the more or less work and what is going to happen with the federal government moving forward on some aspect. A quick comment, i think i agree with what ted is saying and we want the ability to do that and we certainly have cases where we dont have Network Providers and geographies because a Doctors Office doesnt exist in that area. It becomes complex for patient who is live in rural areas and where they access care and how expensive it is. As a plan, there is a way to develop measures and programs where you have a team between and those parts in the state. From my perspective we agree with the flexibility in allowing states to do that work. That was the qualitative standard and not a quantitative force. Thats important, but having said that, there wrinkles with a lot more low income and people coming into the market place. There is a second part of network adequacy, the essential Community Providers who serve that population. We did start with quantitative regulations and 20 of the Community Providers to make sure that the provider who is have the populations would be represent represented. I would be wary of where that goes. A question for mr. Nichol. Have the Medicare Advantage standards created five Different Levels based on the diversity of a community total population and density. Have those failed and recognized diversity among the states . Thats not a question i am well versed on. I have not seen much in terms of diversity, but i would have to get back to you on. Do you have something to mention before . To import them directly and the principals that are there. There those and the Medicare Advantage standards. I certainly will be skeptical of doing that at this point. That is where the rubber will meet the road. The Medicare Advantage example has one distinction, the existence of medicare. You have this market backdrop in the Medicare Advantage world and most people do. I opt to stay in the Medicare Program where as in the exchanges, you dont have the plan that you can pick. We are worried in the exchange population. If there is a market place where there is not a choice you would want. In the Medicare Advantage situation, medicare relieves a lot of pressure on the regulation of Medicare Advantage plans. Related to this loosely, they have recently come out with an accreditation of plans. How is that going to work . Is that going to work well . How does it fit in with what the other parties are doing . Its welcome in terms of what can be helpful and a love of the regulations and once the regulation is having the experience and trying something that worked on doing that. That was not my experience and looking at Different Things through and approaching the software and the regulations that are to be commended. I dont know a lot about those standards, but they look to me when i skim through them to be more processoriented and making insurers working the process of asking the right questions and having the answers on them. The strict bolt you wittom line which i think is good. I think you need to interpret the activity as a subset to inform people and provide information about the type of plans. The enormous venture and the range that is trying to inform people about the different plans and the different providers within the plans and when they are choosing a plan and when they are choosing a physician. You will see an amount of Venture Capital and private efforts to improve the way the marks work. We are at the very beginning of understanding how well all of those new tools that take advantage of data and sciences. We dont know how well we can translate the knowledge into the consumers many more important and how well they will be able to process the information and how that works through in the markets. You will see a lot of stuff being done by different organizations to help improve the markets. When people make comments, i cant handle that and how will i handle more. They are thes that create algo rhythms. They end up trusting and not the ones that say let me look through the data. They get on the thousands of pages of data. Most people will stay right on the surface page and say will you give me a recommendation based on the recommendation. I will start typing and you give me a match of a health plan and i say no, i will give you more information. The process and within a minute or two. They are running all of the data. Its not going to be the consumer looking at the data. Its going to be the intermediaries figuring out how to process it. And whoever gets the result like that, thats exactly how they are thinking about this. The one thing that they slip by is the new information that is personal. Its not which plan is better, but better for me. That requires information that is not just spitting stuff out, but combining it in ways that would be useful to individuals and again, because it involves information and all information agrigation requires value judgments to do that, it remains to be seen. That is the vision they would have. Joyce friedman. With apologies. I will ask a providerrelated question. There have been reports about providers not finding out which networks they are in or thinking they were in one network and finding out otherwise for mr. Nichol and anybody else, i was wondering if there were efforts being made in the model regs to make sure providers are adequately informed. Your question is more about providers not being informed than consumers figuring out that the provider is not there. Is that your i dont know that the model will spend a lot of time on that. Its more going to be looking at it from the perspective with insurance regulators and looking more from regulating insurers and making sure that they have plans that they file with us are adequate and we are looking at it from that perspective reaching out and saying you may think you are in this one, but you are not. Thats a step where its just not going to be in our wheel house to be going that far. In any of the comments you received from providers, did you hear about this . Was this something they were talking about . Thats not one that i have seen. The first thing i will double check on it. When i said what i said about the providers, i didnt mean to imply i am being unfair. I said i do believe the system needs to be fair. Not the least of which is fair, but also one way in which consumers do get a lot of information is from the providers. If they are not well informed from the networks and whats going on f they cant figure out what others are in the network, its hard for them to make referrals in a way that you would want. Its important for the well functioning of the market for providers to be informed. Apart from the most important part of the care, its important to have the information flow here. Just as consumers need to know which hospitals are in the network, the providers need to know. You have to work through the issues. There real issues that i do believe require important attention. Whey meant to imply, before the end of the day, we care about those at least largely. How the patients get treated will depend on if they are being treated fairly. In and of itself, a provider being in versus out of the network is not the ultimate goal. They will take heed. The Customer Service around those issues and the health care issues. One of the reasons is the employerbased system where everyone knows and im not making the choice and its not even accountability. One of the dimensions within the exchanges, i believe increasingly in the market through private exchanges, when they are responding to the retail level to sell the product rather than the employer on the wholesale level and Customer Service and all the issues are going to get much, much better. There is no other system in which the supply chain and the doctors and all of us that are part of the system have as many conflicts with the ultimate payer in the system. They are grown up in a way that is not customer friendly. As we move to a retailbased system, they will be the ones who treat the individual right. Diane . I think if you look at what makes health care potentially work better, its the ability for all the components to be informed and understand whats happening. If you say who are the important parts and in that system, that transparency and the provider has to be well informed and have to understand not just networks, but they are now increasing and the average patient is going to the average doctor saying what do doi with this coexperience. What should i do . Who is the better doctor for me to see . Patients have trusted doctors more than anything when it comes to health care. They make sure the provider systems are laz inform as they can be. How are we provid