Our campaign 2014 coverage continues with a week full of debates. On cspan tonight at 8 00 eastern, the georgia governors debate between governor nathan deal and democrat jason carter. And at 8 00, live on cspan2, the montana u. S. Senate debate with u. S. Representative republican steve daines and democrat amanda curtis. Tuesday night at 9 00 on cspan, the South Carolina governors debate between five candidates, nikki haley, vincent shaheen, tom ervin, steve french, and morgan bruce reeves. And thursday night, live at 8 00 eastern, the iowa Fourth District debate between u. S. Representative steven king and democrat jim mowrer. Cspan campaign 2014, more than 100 debates for the control of congress. Here are a few of the comments we recently received from our viewers. Ive been battling my local Cable Provider here, cable vision in new jersey, for over 18 months now to start offering cspan in high definition. I have never done anything like this before, but i thoroughly enjoyed this program. I never i like the History Channel where i live in naples, florida, and i thought this was absolutely really magnificent. I just sat glued to my chair for the whole hour. And i will continue to turn back to this program again. I just want to start off by allowing cspan to know that i do not watch any other channel on my cable selection besides this. And cspan 1, 2 and 3, so i really want to show my appreciation for this, for your services there and your ability to really keep it mixed up and really lively. And continue to let us know what you think about the programs youre watching. Call us at 2026263400. Email us at comments cspan. Org or send us a tweet. Join the cspan conversation, like us on facebook, follow us on twitter. Live now to the Brookings Institute for a discussion about Health Care Policy and the accountability care organizations. Were getting an introduction now by mcmcclellan, the director of the Health Care Innovation and value initiative. Physicians and other Health Care Providers that are increasingly involved in patient care. Clinicians get more flexibility in care, but they also have more accountability for demonstrating that theyre Getting Better results and avoiding unnecessary costs. The physicians and other Health Care Providers who take on accountability for the Overall Results and costs of a population of patients are called an Accountable Care organization or aco. And as well discuss, acos have been growing in medicare, private Health Insurance plans and state and Medicaid Programs across the country. Now, while this all might sound good in principle, there are some concerns. On the one hand, Accountable Care has been criticized as requiring too much change without Strong Enough support for it. Health care providers have to make Real Investments of time, effort and money to change the way that they deliver care. With bigger changes requiring bigger investments, and the savings from better results to pay for this dont come until later if at all. In this view, the idea of shared savings is not enough of a change away from fee for Service Payment to be able to support innovative payment models. Instead, a bigger shift away from fee for service towards more capitated payments, more are fully person level payments, as and as in the Medicare Advantage program for private Health Insurance plans might be needed in this view. On the other hand, others are concerned that movement away from fee for Service Payments and acos to make them would make them look too much like a replay of the managed care plans of the 1990s that were viewed by the public as skimping on care. In any event, there is a wide range of acos in existence today in a wide range of early experience and growing evidence behind the programs. Finally, many hospital based organizations have been viewed as part of a trend toward consolidation in health care which many see as leading to higher prices. What were going to do today is look at some of the latest evidence on Accountable Care, discuss strategies to overcome the unique challenges that acos face in succeeding in their mission of Better Health and lower costs, and also to provide an overview of the ongoing Accountable Care reforms across the country. Here at the Engelberg Center for Health Care Reform we have been working on issues related to acos and other forms of Accountable Care for quite a while, through our aco learning network and initiatives on value and innovation and health care. Were very pleased to bring together a wide range of experience and expertise from the public and private sectors to address these issues. The issues are very timely. Initial results of early aco experiences are starting to emerge, and while better data are needed, it is time to start looking closely at what the data show and what it means for next steps for Accountable Care were also approaching the next major phase in the medicare aco program, with the net version of aco regulations expected soon and probably including some significant revisions. And both private insurers and states are taking the Accountable Care concept in new directions. All of this should be informed by the discussions were having today. Id like to just mention a few brief housekeeping items as i noted at the beginning, this event is broadcast on cspan and via webcast as well as being video recorded. A full recording will be available on our event page at Brookings Health in the coming days. Were also expecting to have some time for questions in each of our sessions and well be using microphones in the audience for that. I encourage all of you in the room and those joining us by broadcast to follow us further on twitter using the hash tag acofuture. Please also follow the Engelberg Center twitter account and aco learning network. Im going to start with a brief overview of some of the current aco trends. This is an outline for the day, ill start with a brief overview of the current aco trends and results to date. Then were going to have opening remarks from Sean Cavanaugh, deputy administrator and director of the center for medicare at cms. Hell describe some of the latest aco results in medicare and some of the issues that cms is considering in term of the future of the aco programs there. Next a Panel Discussion on what we know about the evidence on acos so far. Well have a short break with refreshments out in the hallway. After the break, well reconvene here in this room for a panel on some of the big issues for acos going forward. And in that well focus on issues like engagement of beneficiaries. Immediately after well have a final session on aco policy issues and solutions on the horiz horizon. So just to begin with a little bit of an overview of where we are with acos in the united states, over the past few years the number of organizations forming acos has grown rapidly. Our own internal tracking shows over 640s a acos in every regiof the country working with health plans, the Medicare Program and state Medicaid Programs. Medicare acos continue to outnumber private sector acos but private plan acos have been growing steadily as well and are part of almost every major Health Insurance program, Health Insurance plan in the country. In addition, 19 states are now in the process of implementing medicaid acos. This slide summarizes some of the current takeup and results of acos. There is quite a bit of variation in beneficiary enrollment around the country and public and private sector. But it is becoming a significant part of both public and private insurance programs. Medicare acos serve over 5. 5 million patients and commercial acos are providing care to 10 million to 15 million beneficiaries for around 280 plans. In the results from these programs that we have seen to date, medicare has released some results over the past months, i think youll be hearing more about that from sean. These results generally show better Quality Performance levels on those Performance Measures that are key part of aco reimbursement. And in the medicare shared Savings Program, the largest aco program in medicare, which represents the step towards paying in part based on beating a cost benchmark while improving quality, doesnt take away the fee for Service Payments that aco providers receive as well, but it does set up a second track of payment. In that medicare shared Savings Program, overall savings were around 1 or so in the first year, with the significant improvements in quality. Thats on top of the slow rate of growth that medicare is experiencing in recent years. And a subset of these acos, about a quarter have achieved significant savings, large enough savings, large enough reductions off of expected trend to get some of those funds back. The shared savings fund back. Ill talk more about medicare pioneer acos in a minute. I did want to spend a moment on private plan experiences so far. As youll hear from our panel, these results are a little bit harder to compile, comprehensively, different plans report on their results in different ways, and perhaps not as comprehensively as we would like either. But if there is a basic finding that is worth noting, i think it is that many of these private plan acos do more than just provide shared savings up front. They provide more investment support through maybe capitated, partially capitated payments to primary care providers as in a medical home, they provide infrastructure support, data, care managers. But in conjunction with that, they also expect more in terms of impact on Financial Performance. That means more risk sharing. So instead of just shared savings, two sided risk, with the providers being accountable in part for Holding Trends close to overall growth in the economy, or achieving larger savings. And facing some Downside Risk if they dont. Many of these plans have shown some more significant impacts on savings as well as in the medicare case some significant improvements in quality with reported savings on the order of 2 to 12 in many of these major private plan implementation efforts. In medicaid, the programs are at early stages, but some promising results there as well. Many of the medicaid plans are also going beyond shared savings and in Traditional Health care to integrate other types of activities such as coordination with social services or behavioral support in other Community Based programs that may have a bigger impact for some vulnerable individuals than just the medical interventions alone. This is a slide that highlights some of the early medicare aco performance. It shows the distribution of medicare plans in terms of Quality Performance compared to the overall medicare Provider Community. Most of the acos perform at or above the 70th percentile, a shift on the slide to the right, towards a higher level of performance, on the quality measures that were established by medicare for this program, particularly good performance in areas of Patient Experience and coordination of care as you might expect. It is also important to note that there are a lot of different kinds of acos out there, some that are led by academic medical centers, some by qualified health plans, some led by hospitals or integrated Delivery Systems. And a growing number that are led by physician groups, often primary care physician groups that are willing to take on overall accountability but with a much smaller number of providers directly involved. And were starting to see some differences in performance, both across and within these categories of acos. The next slide highlights for the Pioneer Program. This is, as youll hear more about from sean, a program for a smaller number of Accountable Care organizations that have been willing to commit to medicare to move further beyond shared savings and to some more significant financial reforms and accountability for both cost and quality. The acos that are continuing in the program are showing some further improvements in the second year relative to the first year. Again, this is percentile of performance. You can see the shift to the right on the slide, thats higher levels of measured performance. This is a chart for the Pioneer Program that shows for their first two years results on both quality versus savings. As you can see here, something well discuss as well, many of the pioneer acos, just like many of the acos overall are doing quite well on the Performance Measures, so theyre over to the right side of this chart, but not some have not done as well in terms of achieving savings. And some of the pioneer acos have dropped out of the program, as you can see from this chart, those are the ones that are the red dots, all of those are ones that did not do well against the Financial Performance benchmarks that were set up by the program. And one of the things that well discuss today is what why is that, what is going on with the benchmarks and is this really row fle reflecting the aco performance accuracy or are there ways to learn from the early experience to try to encourage better performance and lower costs at the same time . So thats a little bit of an overview. I would highlight that a good bit of this evidence came from our work with a range of Health Care Providers, payers, associates, experts, and others through our aco learning network, to compile some of this evidence and share experiences. More to say about that a little bit later. What i would like to do right now is introduce Sean Cavanaugh, the deputy administrator and director of the center for medicare at cms. There sean is responsible for overseeing the regulation and payment of medicares Traditional Program providers, the privately administered Medicare Health plans, and the Medicare Prescription Drug benefit program. Medicare collectively provided Health Insurance coverage for 50 million elderly and disabled americans with a budget of over 550 billion. So sean definitely has his hands full in his day job. Prior to assuming his current role, sean was Deputy Director of programs and policy in the centers for medicare and medicaid innovation, so he came to the oversight of the overall cms Medicare Programs from some experience with the pilot programs like the pioneer aco initiative that i just described, and he there oversaw the development, testing of a range of new payment and Service Delivery models as well. Previously sean was the director of Health Care Finance at the United Hospital fund in new york city. Hes also served in senior positions at Lutheran Health care in brk lynn and new york city mayors of insurance access and Maryland Health services commission. He started on capitol hill on the ways and means health subcommittee. Sean, were very glad to have you here with us today. Please come on up. Thank you, good morning. Im going to speak for about 15 minutes and then leave about half the time for questions and answers partly because thats what mark asked me to do, but partly in recognition, i looked at the other panelists and the people here in the audience and i think very distinguished group and groups like this people like me from the government should do less speaking and some more listening. So my remarks, quickly i want to give you some big very big picture context of how we think of the shared Savings Program. So starting at 40,000 feet and then coming down fairly quickly to the ground level and talking as mark indicated about we are in development of proposed rule for the future, the next generation of the shared Savings Program. Lets talk to you a little bit about where that might be headed. So first, were about four years out from the Affordable Care act and probably more importantly we are one year out from the 50th anniversary of the medicare st