 Thank you all for being here I know that the week before Christmas break is kind of a tough time to think about health care reform But here we are so before we get started. I want to thank Pascal metrics for their very generous donation of the copies of Unaccountable by dr. Marty McCurry who we have here today Read unaccountable and read it not just because it's free Read it because it's really good. I've spent a fair amount of time in hospitals And dr. McCurry shocked me so it's a very very good book. It's worth it's worth the read So I'm Shannon Brownlee. I'm the acting director of health policy here at New America I'm also a an instructor at the Dartmouth Institute for health care and clinical practice And I've just recently become a senior fellow at the Lawn Institute with my colleague dr. Vikas sanny who we're lucky enough to have here today And the Lawn Institute is going to be working on some of the cultural components of health care reform which are crucially important So most of the debate over health care reform has focused on coverage until now That's the date debate that we went through during the first Obama administration leading up to the passage of the The Affordable Care Act and I hope we won't have to revisit the question of coverage again But I do have one comment only in America can possessing a gun be considered a right and Getting access to health and health care be considered a privilege and until we see health and health care as rights Many of the reforms that we're going to talk about today may be very very difficult to achieve So the good news The good news is that the conversation around health care has finally begun to expand to quality and safety Americans are increasingly aware that the quality of the care they receive is not what it should be especially considering how much we pay for it And they're getting a glimmer of understanding that at hospitals are not necessarily very safe places to be Dr. McCurry's book unaccountable is one of the most honest and clear windows on how hospitals really work And I'm looking forward to his remarks today But the next conversation in health care has to pry the lid off of productivity and efficiency An industry can't be productive until it is efficient and health care is still in the dark ages when it comes to basic industrial efficiency So why has health care been so slow to analyze the impact of changes in organizations on improving output Output and lowering costs and why has there been this been such a neglected theme in health care policy? Other other sectors of the economy have streamlined their processes using using systems like the Toyota production system Which helped make Toyota one of the most profitable care profitable car companies in the world and a tool Guwandi who's a board member at the New America Foundation His recent article in the New Yorker suggests that hospitals could learn a thing or two from the industrial processes of yes the cheesecake factory So we need to start talking about this crucially important aspect of improving health care and But I want to leave you with a thought that we may have time to explore today Or we may not but it's something that we need to start thinking about very carefully The hospital industry is deeply in debt to the tune of about a trillion dollars in hospital bonds It's equal to about a year's worth of their revenue and most of that borrowing is going towards expanding Capacity and has gone towards capacity in the past more cath labs more expensive CT scanners More intensive care unit beds But there's a day of reckoning coming coming and that day is when hospitals will have to justify this expansion and it's coming soon Because today hospitals are facing an incredible challenge a perfect storm if you will a financial pressure And it's coming from three different directions Number one are public payments Congress has been talking about controlling Medicare and Medicaid spending for decades and they seem really serious now as The federal budget becomes a more exclusive focus in Washington doctors and hospitals are going to have a harder and harder time Avoiding the cuts that everyone even the military has already started to feel So those cuts have begun things like read mission penalties We'll start eating into hospital revenue and on top of that there are rumors that academic medical centers may see cuts in their payments For running residency programs. These are the training programs for young physicians And that may be part of the fiscal cliff deal And if they're going to be other Medicare cuts in that deal, it's hard to imagine that some of them aren't going to affect hospitals So private payers are stepping up. That's the second threat Some of the big ones are now taking a much more active role in finding cheaper better care Walmart has a program called centers of excellence Starting in January 1 over a million insured medic Walmart employees and dependents will be able to get some complicated procedures like bariatric surgery at a few high-quality low-cost Institutions the company will fly them out to the Mayo Clinic Virginia Mason and Scott and white in Texas fly them out They have no co-payment and the hospital that the company will end up saving money by sending them to these high quality places the third threat is That we're beginning to understand that getting the best care doesn't meant me and spending lots of time in a high-tech Cath lab or ICU unit the best care keeps people out of the hospital in the first place It's not to say that you don't need an ICU unit at times or that you don't need a stent at times But in one of the things that we're learning is the community-based care that keeps people out of the hospital ends up being better care And it means that people need social support They need to stay healthy and that kind of care is happening in isolated pockets around the country Jeff Brenner's work in Camden, New Jersey. For example, you may have read about his work in another a tool Gwandi piece called the hot spotters It's happening at places like group health and Puget Sound of Puget Sound in Washington State and Intermountain Health in Utah And what these examples demonstrate is the power of better community care to produce better health and to keep patients out of the hospital Now that's great for patients. It's great for payers But keeping chronically ill patients out of the hospital means a huge source of revenue for the hospitals Is drying up These three sources of downward pressure on hospital revenue represent a triple threat in the face of lower revenue Hospitals must become more efficient Beyond that some hospitals will have to shrink or close We have too much excess supply in many parts of the country to keep running them at full capacity Now right sizing the hospital industry is inevitable, but we do have a choice We can see what's coming ahead and try to wind it down Deliberately and intelligently or we can let the market keep going until the music stops And when that happens some hospitals are going to fail They'll be forced to shut their doors or radically reduce their services And there are a lot of good reasons to avoid that latter option catastrophic failure Hospitals are huge local employers and when they shut down, it's not good for communities. It's not good for jobs To the bonds are held by somebody the mortgage crisis is a pretty good dress rehearsal For what happens when a large sector of the economy starts to default on loan obligations all at once And while there are major differences between the hospital bond market and the mortgage debt market the consequences of frequent hospital Defaults are difficult to predict and they are worth avoiding if possible Finally market driven hospital failures are going to hit the most vulnerable hospitals first And these are often the vitally important safety net hospitals the public hospitals or hospitals the serving large Medicare and Medicaid populations They can't run more patients through their cath lab to get more cash And they are going to be squeezed as payments to hospitals are squeezed So I want to leave you with it with an image Last week I saw photos from a hospital in New York City one of the major academic medical centers And it was in the emergency room and patients were sitting two to a bed in hallways and These are not just poor patients. These are rich and poor alike are being are in this emergency room because the hospital Doesn't really make money on this emergency room. And so it hasn't invested in the emergency room We need to keep people out of the emergency room if we possibly can but if they need to be there We need to make sure that it's run in a safe way a high-quality way as possible So we have to start investing very differently We have an ethical responsibility to protect people and we have an ethical responsibility. I think to protect safety net hospitals So with that I'd like to introduce our speakers I'm very pleased to have Marty McCurry who's a surgeon and a health services researcher at Johns Hopkins and the author of Unaccountable what hospitals won't tell you and how transparency can revolutionize health care. He's sitting to my far right He was active in the development of the surgical checklist Which many of you have probably heard of and he's a regular medical commentator for CNN and Fox News We hope C-SPAN won't hold that against him Next is congressman Jim Cooper who's the US representative from Tennessee's fifth district Which encompasses Nashville, which is kind of the center of gravity for for-profit hospital industry USA Today named Mr.. Cooper one of the brave 38 of a tiny band of heroes in Congress for his work on a bipartisan budget plan Jim Cooper really knows health care and he is bar none the smartest person up on the hill when it comes to thinking about it from a legislative perspective Dr. Vikas Sanny is the president of the newly renamed Lown Institute in Boston He's a practicing cardiologist with the Lown group a lecturer at Harvard Medical School and a research associate in the Department of Nutrition at the Harvard School of Public Health and I'm very pleased to say that he's also my my colleague in working together on this on the initiatives at the Lown Institute and In April in 2012 we convened the avoiding avoidable care conference where we gathered a group of clinicians to talk about the problem of overuse and over-treatment and Finally last but not least it's my pleasure to introduce Kavita Patel Who is a fellow and managing director of delivery system reform and clinical transformation at the Engelberg Center for Health Care Reform At the Brookings Institution Kavita was here at the new America Foundation where she was a valued colleague and she is a practicing physician Who has also worked in the White House and the Senate and she will serve as a respondent So with that, thank you very much Well, thank you Shannon, it's quite an honor to be here I consider Shannon to be a mentor really her book overtreated was one of the great books that sort of defined the status of the crisis and So I'm feel very honored here to be with all of these experts here. I'm just a simple country doctor blessed with many friends and It's good to see some of those friends here Leah binder of the leapfrog group Drew Ladner and others. So thanks for coming You know in medical school, I remember learning what a nosebleed was they said that it was This term epistaxis that is when you have a hemorrhage from your nasal region You had epistaxis and I remember raising my hand saying isn't that this the same as a nosebleed and They said no, it's epistaxis And I said well, what's the difference between that and a nosebleed? They said nothing. It's exactly the same thing Well, can we all agree collectively as a profession now to switch the name to nosebleed and They said it's epistaxis And I realized that there are these different orbits That are talking about the same thing in health care So I was really bothered by this kind of language that almost made medicine seem like an aristocracy I'd been well aware of the eroding public trust. You talked to patients that are frustrated with their health care You talked to my dad who is an oncologist and practiced his whole career just retired actually two months ago from geisinger But I remember talking to him and I said, you know, it doesn't seem like we're Connecting anymore with the general public. It seems like there's a lot of distrust Every five or ten years the New England Journal of Medicine puts out a research study That about half of all the patients we see either don't follow our recommendations without us really knowing and They're out there seeking alternative health care And I thought what a massive disconnect we're prescribing these things we think people are taking them and my remember my dad said write down your observations and Just keep track of them and you'll be amazed how when you look back on them You'll have have completely forgotten about some of these observations and that's really the reason I wrote unaccountable. I had these stories that I'd share going out to dinner with friends and They'd say, you know, you should write that down put it in a book and really that's All the book is it's just sharing firsthand some of these observations But you know when you're a doctor and you have to become a patient or you're a nurse and you have to become a patient the health care system seems Completely different. It's almost as if you stepped outside of this world and you look back on it and you see this giant monster and I remember when I had an issue with my knee and medical school and I was trying to To get in with somebody who could tell me what was wrong with it. I felt I felt humiliated I mean I was being ping-ponged around from doctor to doctor. They didn't want to deal with me I didn't fit one of the classic conditions in the book The x-rays really didn't show anything and it it took a long time for me to find somebody who sat down listened did a good physical examination and Essentially told me my knee was going to be fine with certain types of physical therapy And it would be okay for me to go on and choose surgery as a profession. I was worried about standing up And then I asked Can I get a copy of my records? And I was pointed to another office poor doctor. He he just didn't know how it worked and this other doctor This other office Said you have to go down to some basement where it was dark and spooky and cold and There was some little window Sort of like a rundown bank teller window and I remember asking for a copy of my records and You would have thought we needed to get an act of Congress pass. No offense, but you would have thought it was a major Test and I remember when I went back to the floor and the nurse had a copy of the records there And I said can I just photocopy that she looked at me like Who are you? You know trying to get a copy of your you know, why would you want to do that and I realized you know for From the perspective of those of us delivering healthcare it can seem like we're delivering state-of-the-art care That's doing amazing things but from the perspective of a patient sometimes the the field can appear to be a closed-door culture and There's no villains. There's nobody who's saying you're not allowed to have this It's just we're all doing our little jobs. We're doing what we're told to do but It's not very coordinated and I asked the patient About a year ago when I was interested in this general subject of How do patients choose medical care and I said just for fun I said tell me why you chose to come to this hospital and She said because the parking is really good here And I and I thought okay, and I asked the next patient in clinic that morning I said before we start can I just so why did you come to Johns Hopkins? Why'd you choose this hospital? He says well my my mom was born here I thought okay, and then I asked somebody else and they said well the parking at Mercy is really rough And I thought what is going on here? You know, we're hearing. This is one fifth of the US economy It's a free market no matter what anybody says about it being a Communist system or socialism people choose where to go and the hospitals want your business and they put billboards up and they Have valet services at the lobby of the hospital But what are people using to make their free market decisions in this space? And it turns out one-fifth of the US economy is a free market that I really believe is dysfunctional when you've got outcomes that are superior and patients telling Telling us they're just coming here because the parking is easy the competition is there, but it's at the wrong level and Now as a society We have to ask ourselves a fundamental question and that question is Do we believe the public has a right to know about the quality of their hospital? And I think they do for the first time ever we've got ways to measure hospital performance and It makes sense that that performance can be used as the level of competition for hospitals instead of parking in billboards You know for a long time We haven't had good ways to measure hospital performance as a matter of fact many of us doctors have protested the idea of measuring performance because the metrics were so crude and They were not exact and they would in fact punish many of us that take on high-risk cases Or take on borderline cases that other doctors won't take on or take on patients that are obese or From come from a slow socioeconomic status or patients that we know we're going to have a tough time with follow-up And their outcomes are going to look bad We guarded the public availability of data for a long time and I was a part of that But now we've got new metrics the field of measuring quality has matured and The doctors groups have gotten together and created formulas To measure quality in ways that are fair and risk adjusted. We've got cardiology professional association saying The time from when you say I'm having chest pain to the time when you have an EKG is a marker of quality The surgeons groups have come up with formulas to measure complication rates and They're measuring complication rates, and it turns out at some hospitals the complication rates are 400% that of other hospitals all of which are good hospitals So now we have a dilemma as a society based on based on these advances in the last few years Do we believe the public has a right to know? About the quality of their hospitals and I think they do I think that We have had these metrics leaking out to the public through different websites and different avenues State departments of health have put some of these metrics up But if it's not easy to understand and readily available to the consumers It hasn't had a big impact and for the first time now. We're seeing HospitalSafetyScore.org consumerreportshealth.com we're seeing Websites Serve as sort of the master board for patients to look up the quality of their hospitals And that's one of the great things we're seeing with hospital compare so That's all I really had to share. I just want to say I'm really honored here to be with such great experts And thank you for being here I'm the one I'm the one who feels honored to be here because I'm a huge fan of Shannon's her book Overtreated is truly important I hope everybody in America reads it and now we have a new exciting Fellow entrant in this field Marty McCarrie's book Unaccountable is amazing I spotted it a couple months ago in Nashville have gotten everybody to read it that I can find and I'm going to use it My class at the Owen School of Management at Vanderbilt University this winter The power of narrative cannot be Overestimated, you know one person even said the plural of anecdote is policy So these stories that Marty is telling and who wouldn't want him as their doctor You know to be fair and calm Intelligent balanced and also to understand the system of medicine That's extraordinarily important and more and more of our physicians need to be able to do that Unfortunately, I have the job of talking to you a little bit from a policy perspective today And that's not nearly as exciting because I don't do kiss and tell or anything like that But the policies we've got to work on are fundamentally to save so security Medicare and Medicaid And in order to save those programs you must be for reform Magical thinking doesn't save the programs political speeches don't save the programs Chickening out doesn't save those programs Unfortunately in a political environment normally we follow the path of least resistance And that will mean that self-security disability program will be out of money in 2016 in this presidential term it means that Medicare Part A will be out of money in 2024 which is not that much further away and Social Security itself will be out of money By 2033 Those are deadlines that we must start adjusting now to meet Because these are such vast and important programs that it takes years to start heading in the right path Now there are many other programs that are important They're not trust fund dependent as much and they're harder for accountants to comprehend But it's possible that those programs are actually in worse financial shape Especially in a weak economy Than the so-called trust fund programs. It's just we don't have the tools today to even measure Those shortfalls as well. So this is an acute problem. Of course most of my colleagues like to say, oh, it'll be okay Everything's fine. We love stories with happy endings. I do too But I want so security Medicare and Medicaid to have a happy ending And I think the best way to do that is to tell the truth now and to start acting appropriately The way I calculate it every day that we wait on a solution costs us another 11 billion dollars billion with a B So this is a shocking realization the cost of our dithering Could actually fix the problem But because we're unable to confront reality The problem grows worse On the good news side, although it's still politically controversial There are many reforms in Obamacare which if properly implemented can go a long way toward improving reforming the system Ipab is a very important reform that needs to be properly implemented the independent payment advisory board Comparative effectiveness PCORI is another extraordinarily important thing So many people think falsely that the FDA tells you what's worth buying and it doesn't it never has it only tells you What's a poison or what's slightly better than a placebo and that's not good enough to know what's worth buying ACOs are important if properly implemented and they're spreading nationwide We do need teamwork in medicine and I love to see Dr. Lead teamwork There's so many other reforms. It's easy to malign the Cadillac tax But how many people know that the government's third largest health program doesn't even have a name At least the Cadillac tax starts getting at that problem Exchanges, you know, there's so many elements of this bill that are important that the need to be properly implemented of course The things that are fun more fun to talk about those are usually the cost enhancers not the cost Minimizers, so we have to work work through the situation as I said at health conference last week when people said Oh, there's no cost control in Obamacare, then they proceeded to trash all the elements that actually provides some cost control the Truth is we've got to somehow get health spending to no one's really talking about cuts Everybody's really talking about slowing the rate of growth So let's be honest about that and if we can slow the rate of growth to inflation plus 1% Which would be the dream of any other industry We've solved like two-thirds of the problem that shouldn't be that hard because health care has been growing at inflation plus two and a half percent So it's really just that small percent or two different so it makes a difference But as Einstein once said the most powerful fourths on earth is not nuclear power. It's compound interest And we've got to get these big these big numbers, right? Let me mention two other categories of ideas that are not as much fun to mention In fact, I get in political trouble by even breathing them But it's important my definition favorite definition of leadership is expanding what can be talked about without embarrassment But CBO put out a book in 2008 health care policy options that as its amazing list of scored Savable endeavors that politicians flee from we deny that that book was ever published I don't want to read it, but these things need to be looked at and examined not that it's an exhaustive list But it's a great beginning point Some of these ideas were hinted at in Simpson bowls But it's also important to realize that other policy ideas some which are taboo at least in certain political parties such as premium support And I'm talking about premium support as suggested by Henry Aaron and Alice Rivlin Actually, I happen to be Democrats, you know Ideas like this need to be examined before they're dismissed The Ryan Wyden version to keep Medicare fee for service as an option Should be more closely looked at than it has been and one of the most exciting developments going on right now It's built on the Dartmouth work of understanding the delivery of quality care in America Understanding senseless geographical variations the Institute of Medicine itself has embarked on an amazing project right now a blue ribbon panel and There's great hope that it will provide some sense of geographical equity in this country, which we've never had before But those are all still in more or less the tame category Let me mention an even wilder set of categories and I'm going to divide these into three legal a lifestyle and professional but many of us who Focus on health care economics think we need all-payer rate disclosure Because the Medicare data is accessible, but hardly any other data. It really is we need transparency at all levels It's kind of shocking that for years We didn't really even understand how PBMs made money or dialysis companies major sectors of the industry like that Probably need to amend the federal prompt pay law to curtail fraud You know, it's great that the federal government's the fastest payer in the country but it also leads to Fraudulent payments sometimes We probably need to update the definition of disability and so security disability because it hasn't been updated since the 1950s You know why has Congress neglected that for over half a century? Reducing cost-plus reimbursement is a way to start getting things under control Stopping the prevalent practice of Medicaid gaming. It's amazing how almost every state enjoys gaming the Medicaid system not to benefit beneficiaries, but to raid the Treasury Ending direct-to-consumer ads on television by pharmaceutical companies would help. That's only five billion dollars a year Reforming the FBHPP program the federal employees health benefits program to vote better competition would help How many people know that Blue Cross Blue Shield has gotten a free billion dollars from the federal government every year since 1986 the blues and only the blues like how is this fair? Other things probably a new program for dual-eligibles FQHC's federally qualified health clinics need reform and Now that we're approaching more universal coverage. How can you still justify the tax exemption for 85% of Americans hospitals? You know, this is a taboo subject, but even a senator Grassley is willing to think about it in terms of lifestyle choices Obesity is a scourge about limiting food stamps to healthy foods How about honest labeling of clothing sizes? How about if you take up two plane seats you have to buy two tickets? How about actually spending tobacco settlement funds on smoking cessation today? Only 2% of that money that huge windfall that public health windfall is actually spent on its intended purpose 98% has spent on other things One of my favorites TVs for kids. How about if it were powered by an extra cycle? Then people would burn calories while they're watching the programming But in the professional realm and I'm a big believer and doctors taking leadership here. I wish we could empower doctors to say no Because sometimes that is very necessary in the clinical setting. I wish we could get specialty societies to really reduce abuses You know, we haven't even gotten complete innovate implementation of the promo those checklist yet We need sensible malpractice reform We need a good Samaritan organ donor chain, you know, it's amazing what can be done by proper linking up of donors and donies Even becoming skilled users of medical technology information systems Many doctors have nurses to do all that and getting good at that The whether it's an EMR or physician order entry would be greatly helpful Just simply reducing over medication would be huge. I'm from one of the states It's one of the most over medicated the country including on prescription narcotics Why so I think elected officials and public employees have a real chance here to lead not just by talking about it But by actually being the guinea pigs first We are subject to Obamacare, of course as we should be That's a form of leadership But an even greater form of leadership is saving these vital programs for future generations Because the long term is not a long way away The long term is now the long term is Solving the fiscal cliff problem and every day we wait costs us another 11 billion dollars So thanks for letting me be here Thank you. I also want to thank Shannon for giving me the opportunity to be here I'm a clinical cardiologist. I've been in practice and been seeing patients for over 20 years and Though Marty stole my line. I actually am a country doctor. I was In practice on Cape Cape Cod, which once upon a time was the country in a community hospital and saw how Things work quite outside academic centers and other settings And so this may be this panel may be a little bit Like several blind people all trying to describe the elephant, so I'm gonna go at it from a very different angle The first thing I want to key off is something that Shannon said about productivity and I think there's this really a fundamental paradox at least in health care when it comes to productivity The Toyota model of production really works if you're making widgets and if you're in a hospital and you're making Process or procedures It is subject it you can apply those techniques and hospitals are doing so and I think that's all to the good because any unnecessary fat in processes is Worth removing But the reality is Marty told you a story that gets to the heart of what clinical medicine is like which is finally He got to somebody who sat down Took some time and With a history and a physical Figured out enough to get Marty to where he needed to be Now that's extremely important But in many ways in medicine that takes more time not less So the real question is how do we parse time in the system and how do we do it in a way that Optimizes efficiency and productivity But when we do that we have to keep our eye on the ball. What are we producing? Are we producing procedures or are we producing health? And if we're producing health for our communities for our workforce, you know, for our society Then in fact what we have to be thinking about is how hospitals fit in that environment And that's a very different frame of reference So I think that's an important thing for all of us to keep in mind That's sort of at the very high macro level and at the very microscopic level at the interaction between a doctor and patient in the exam room Exactly what Marty described Is the other sort of crucible really of how change could happen? And I think what I want to impart is a sense of these Staggering opportunity the really staggering opportunity that exists if we were really to change many things about how we practice medicine I certainly agree that doctor led reform is important and in fact necessary But I also think that My profession has dropped the ball a little bit with regard to issues of stewardship and appropriateness And I think that may be changing and that's I think a very healthy and optimistic note to sound Shannon mentioned the conference that she and I organized in Boston in April But many of you may know the American Medical Association Medicine has been pushing a campaign called choosing wisely which has elements that I think can be expanded enormously And I think the clinical community can do a lot to own some of the problems, especially the problems of unnecessary inappropriate care I'm a clinical cardiologist. I train with Bernard Lown and for 40 years we've maintained there has been far too much Bypass surgery or stenting to be justified on the basis of actual outcomes And in the last couple of years I've been able to do a lot of things that I think can be expanded enormously And I think the clinical community can do a lot to own some of the problems especially the problems of unnecessary inappropriate care In the last five years, ten years, we've finally started seeing clinical trial data talk about the need for PCORI and other kinds of research We've finally seen the data that supports some of what we've been saying But not a day goes by when I don't encounter a patient who has been told they need a bypass They haven't even had a stress test Or patients who have no symptoms and have had an imaging study and don't quite understand the rationale and the path for moving forward But they end up on an assembly line very much like any of us when we become patients in the system we have So I want to put a plug in for a renewal of the doctor-patient relationship as trite as that sounds Because I think in many ways as I say there's a lot of leverage Estimates of the Institute of Medicine from their work on the waste in the system Article in Journal of the American Medical Association by Don Burwick You know the figures are staggering, they're in the two, three hundred billion dollars per year range Now getting from here to there is clearly scary and a major challenge in terms of the transition But if we were able to do that I think a lot of the physical problems that we're facing that are causing such conflict Actually you know have a chance of being solved with what we all want which is better health care at less cost and the same outcomes So I think that's important. In that regard there are some moves and I think we're beginning to see something Some hospital systems are beginning to look at the community in which they operate and the level of community health And there's interesting work emerging actually I heard Tom Frieden on Friday head of the CDC talking in Boston about Some interesting data that's emerging suggesting that if hospital systems can deploy the right IT and deploy the right interventions And invest in the right way they can have impacts on things that public health people traditionally thought you know That medical care system can't do that. So that's also a cause for optimism But the only, in my view the only way that'll really get turbo charged is if accountable care organizations and hospital systems are truly held accountable Not just for the care of the people who walk in the door but the care of their catchment areas or their communities I know that sounds a little bit crazy perhaps but I think something like that would actually engender a change in thinking that we desperately need I haven't agreed with Shannon. We're probably have too many hospital beds based on you know the kind of system that would really be a learning system that optimizes the value And it's very much like base closings you know it's like Lake Wobagon everybody's community hospital is above average and it's somebody else's that should close But I think you know the horses out of the barn on that one I mean one of the people involved in the Walmart initiative that Shannon told you about When I mentioned you know these people being sent to Mayo or Virginia Mason or elsewhere That's going to have a significant impact on the local healthcare marketplace and in some areas community hospitals are going to take a hit And his response was well many of them really should just be outpatient clinics don't you think? And I don't think the people there would agree but I think we face a real challenge in navigating that maybe we need a base closing commission kind of an approach for hospitals And then lastly I think there's good evidence in the public health literature that medical care achieves good health outcomes for a portion of all the good health outcome that's out there that we could get And much of the rest is really from non medical care and it's a lot has to do with prevention it has to do with lifestyle it has to do with how we organize transportation How we organize food I mean I think everyone here gets that but I do think that one big problem that we need to address or think about is that the ROI the return on investment of those kinds of investments is very long Now Jim was going to laugh I used to think that the ROI was so long that you couldn't really expect insurance companies to take on that kind of investment and prevention programs Because our forces labor force is so mobile they'd lose their premium paying customer before they'd reap the benefits of those investments So I used to think well it ought to be the government because they have a long term view I guess not I mean effectively the view is the election cycle so we have a problem as a society how do we make those kinds of long term investments But we must and if we do then some of the payoff from prevention which I know is disputed quite often some of the payoff from prevention can actually be realized but it can't be realized in short term horizons So I'll stop there Well I have the most fortunate job where I get to react to everything but I'm going to offer by reacting I actually want to try to blend a little bit of what's said and also thank Shannon and acknowledge some other good friends in the room Phil Longman is I think still in the room hopefully he's also written one of the best books that I think should be on everyone's must read list called Better Care Anywhere And it chronicles and talks about the innovation and why the VA emerged as a system that had been kind of the care for the last resort to the most principal choice of care and one that I think sets the trends And I did part of my training so we seem pretty doctor heavy on this panel I realized and that's not intentional but certainly speaks to I think the culture of medicine and certainly I was often told we all have our stories from medical school I was often told that the most powerful thing I had was my pen and now it's probably the enter key although sometimes I'm like thumping on the keyboard because it drives me crazy with my electronic medical record And I practice in full disclosure at Hopkins but in Washington DC which is a whole other conversation that I want to touch on with hospital employed doctors And I think that it is still true however that we as physicians initiate so much of both over treatment and then in many cases I often find myself in situations where I'm worried that I'm under treating or under diagnosing Or not thinking partly because of time pressures partly because when patients come in and especially these last couple of weeks I've been in clinic with coughs and colds It's just so easy to treat with a Z pack and everybody knows about the everybody knows that this happens yet I feel like we all go into our little with our white coats into our rooms and we practice this evil doing of over prescribing And in turn I am also under diagnosing and not attending to many of the things that are driving some of the clinical care So from a clinical perspective Marty's book I think opens up a very general audience to complex concepts in a way that's very approachable And I think I think Mr. Cooper hits on how that causes a real kind of clarion call for policymakers to actually do something about it The more the public understands about how screwed up our healthcare system is the more it's incumbent upon those of us who live and work in this town and feel like we represent people's interests and certainly an elected official But then those of us who focus on policy in our day to day lives in a non-elected capacity we're really stuck kind of holding the bag and going well now what do you do about it We've got this trillion multi-trillion dollar problem what do we do about it And I think Vikas and Shannon and Marty and Representative Cooper have certainly hit on a couple of points and I wanted to weave in some of the clinical with the policy by highlighting some of the future trends At Brookings I spent a lot of my time working on accountable care organizations and I have to tell you at first you know several years ago when Elliott Fisher and Mark McClellan would talk about ACOs I thought what is this mythical creature this ACO this unicorn of delivery systems that's going to fix everything Well now we have ACOs we have over two million beneficiaries in Medicare that are enrolled in accountable care organizations and I have spent time in some of these organizations And what's fascinating is when you talk to patients they have no clue what you're talking about they're like ACO is that a nursing home I do not want to be in the nursing home Is my doctor and then the follow-up question is is that in network or out network because if that's out of network I have to pay more and I don't want to pay more So there's still a disconnect with how promising a delivery system reform can be and the future trend is for everything to move towards something more accountable The phrase accountable care and innovation in health care are the most often overused phrases so I couldn't agree more as a future trend that it's even more incredibly important for the public to have a deep understanding of what this means And then I wanted so that's the first trend the second trend is kind of telecare and telemedicine this highlights a policy conundrum because as most people know Medicare does not reimburse for telephonic or certain aspects of telemedicine And that's still even with as much as was done in the Affordable Care Act and progress made there are still some limitations on what we can do and that causes people to default to telling patients You know what I need to see you in my office which only drives up cost and causes a lot of unintended consequences People are one thing that's been fascinating as someone who worked in a Democratic administration was to see this initial wave of kind of vitriol and hate for health reform But now that we've been a couple of years out I have seen such a surge in the private sector and in entrepreneurialism and in many nonpartisan encounters around how much opportunity health reform has created to allow for that often overused phrased innovation in health care But especially in aspects of getting care to patients in difficult settings so things like ZockDoc which is an online I'm no money from these people I should get some I suppose if I were smarter But things that are making appointments easier they're now looking at how to pair that with quality data and then to add to that to try to steer you to doctors who are you know supposed to be by metrics better for you So that's a trend that will only continue we're not going to see reversal in that and that's a good thing but from a policy standpoint we're going to have to kind of think about how to make our Medicare And then ultimately also our Medicaid system even though that's a federal state partnership to be a little bit more responsive to some of these future trends Cost-shifting to consumers my husband works for a Fortune 50 company and there's actually serious conversations about high deductible health plans and purchasers I see Leah's obviously probably sits in this centrally There are many conversations now about how employers especially large employers can think about reducing costs when they think about the spend in health care costs for their employees Wellness programs certainly have their place in the affordable care put pieces of that possible for tax deductions etc to make that a more attractive incentive But on top of that there are bottom lines quarterly reports and investors who need to have returns on their shares and we're starting to see at the Johns Hopkins system the employee health plan has moved for the next year Has moved to a higher deductible plan and a tight network where if you it used to be that if you saw someone in the Hopkins system there were zero co-pay and now they've implemented co-payments for even providers within your own system So this is just one of a series of trends while we're trying to bend the cost curve and do all these really amazing kind of design redesigns of care It still presents a huge challenge that I think is all the more for kind of responsive policy making but then responsible clinical leadership and I can't say enough about that And then there's so many things that are kind of I've never met more medical students who were comfortable being employed and salaried and I'm not here to tell you that that's a good or a bad thing But I will tell you that certainly that kind of the in my community practice with most of the physicians I'm the youngest in practice and I'm pretty far out of medical school And so most of the physicians in our practice were purchased kind of lock stock and barrel and have all either calculated when they're going to retire to kind of just get to retirement and then get out of this system Or they're trying to calculate how much income they can make and kids tuition things like that But if you take a stock of like just people coming out of school or out of residency you'll see the majority of them are one very comfortable being employed and thus being salaried or having compensation done differently than in a productivity manner And number two there are much more comfortable with kind of not just electronics they're much more comfortable with interacting with their patients in a very different modality than white coat in an office And that's I think that's a positive I do worry however given the kind of concerns that Shannon raised which I share about hospitals needing to meet margins and deficits and where they see opportunities as well as what I see every day just in the real world Which is that if you're purchasing and you're buying up a cardiology practice you're buying up an orthopedics practice you're buying up primary care physicians There's certainly kind of an understanding about the referral pattern within those purchased doctors and there are certainly whether and certainly nobody's doing anything I hope illegal in this regard because patients are free to go as Marty mentioned where they want But the truth every time I get asked you know doctor I need to or we agree that a person needs to see a specialist they say to me where would you say you know where should I go I mean it's then they rarely come to me and say Here are the names of the people I want to see from my orthopedic surgery referral they often look to me and if I'm working within a system in which I am incentivized to keep people inside of that system that may be a good thing But if we're only promoting the same kind of over treatment and avoid kind of unnecessary procedures and putting them down that cardiology gauntlet without being thoughtful as to what that means We could see potentially in the next generation of healthcare we could see these perverse incentives crop up in a very different way than what we talk about right now in a fee for service setting So I do think it's important to have a very transparent I couldn't agree more about transparency kind of all pair rate setting or at least having an honest conversation about how money changes hands and how private pay contracts help to subsidize an offset Medicaid and Medicare which is all very real to most people in health care and I think that it's books like Marty's books like Shannon's books like fills who really bring this dialogue into a very general conversation that also intersects with education labor employment opportunities that is critical so I look forward to any questions and hopefully can delve into more thank you Well I'm going to take the moderators prerogative here and throw out the first question so Mr. Cooper you said that you need to empower physicians to say no I'd like to ask you and Dr. Sanny to talk about that from the policy makers perspective are there things that Congress can actually do that will empower clinicians to say no and when I say no when we say say no what we really mean is how I think something broader than simply saying to the patient who comes and says I want celebrax or I want knee surgery but more the ability to say this is what's really right for this patient despite what my hospital may need me to do Marty talks in the book a little bit about about the hospital putting pressure on surgeons to do more procedures because that's how the hospital makes money so so for the for the clinician to be able to still all the voices they're saying give more because you make more money because your hospital makes more money etc. but also when the patient comes to you so if Mr. Cooper can talk about policy things but first I'd like Dr. Sanny to talk about how the clinician does it because you've been doing that for a long time at the well first of all it's rare indeed that a patient comes and says I want X you know the heart of being a professional is to put your information knowledge at the service of the other person that's really what you're supposed to do and in my experience you know I could get a patient to do practically anything if I said it right you know and we know exactly how that's done sometimes for good and sometimes not you have a widowmaker you are lucky you came now we know how to fix this you know so I think at the heart it's about how you actually engage the patient so I'm going to turn it around a little and say we really do need to kind of revive and resuscitate the patient and all this because I hate to say we're all going to be patients sometime and the kind of care we want for ourselves and our families it's really what the system needs to deliver and in that regard I think one important thing is that the amount of hard settled science in medicine is significant but still less than 50% I don't know what would you say Marty yeah and that means there's a lot of care and a lot of decision making that depends a lot on conjecture opinion experience and preference and I think you know there's a movement in the land called shared decision making and I hadn't actually heard of it I'm sorry to say until a few years ago but in fact it is the case that when you look at the pros and the cons take time and ensure that the patient really understands the tradeoffs it's really not that difficult for patients to come to a conclusion and what the data suggests and I found this astounding but Al Mully from Dartmouth shows this slide and what the data suggests is that if you take a country take a region like Toronto, Ontario and Canada where rates of bypass surgery are low by American standards they'd be in the lower third let's say and if you truly initiate a shared decision making process where patients fully understand what's involved patient choice for bypass surgery drops off the graph. I like to joke that becomes the lounge rate and in fact it is the case that quite often we oversell the benefits and we under emphasize or don't mention the potential harms and I think as a caring profession there's a good impulse there which is you know we try not to scare people with outcomes that are small probability but nevertheless real but this is where you know we all need to get treated like adults and understand what the tradeoffs are. This is a couple of stories one is the proverbial case of ear infection for the kid the doctor prescribes antibiotic it's usually a viral infection the doctor really isn't even treating the child treating the anxiety of the parent and that's gone on so much we've probably run through 400 years of antibiotics in 40 years as a result and it's always the latest pink medicine. Another example of what Dr. Brent James found in United Intermountain when the people weren't even bringing babies to term and the NICUs were happy because they were full and just the simple process of actually determining the conception date and having a full term baby minimized so many complications and yet that was not preferred practice and it was not done he had to persuade his colleagues to get that done. This is astonishing and at least my doctors are telling me with the you can't watch a ball game now without learning about more medication than sports scores and people are coming it's almost a sign of respect today in the modern medical practice. If you don't hand them a script then it's a sign you didn't really believe what they're telling you and it's amazing the transformation medicine and the medicalization of so many things most psychiatric care is now pill driven not diagnosis driven. So I think what you raise of getting this right the doctor does need to say no when appropriate not to say no to say no but to help steer the patient in the right direction. And do we have any sort of high level policies that can actually help that process I mean I'm thinking fee for service is part of the problem here and Medicare is fee for service. You're exactly right it's not just a defensive medicine that's being practiced from doctors are afraid to say no less they be sued having angered the patient but also that incentive to make more money by doing more has been pernicious on the profession. But now you know most Medicaid plans are managed care we're getting away from it but it's much slower than it needs to be remember the time value of money every day that we wait is a crushing economic burden. Can you imagine Medicare working in some some some fashion similar to the way state Medicaid plans work where there is a there is a effectively a capitated plan. Well Medicare Advantage plans are amazingly popular today they're growing like a weed now part of that is we're paying them over Medicare fee for service reimbursement but some of them are actually getting well properly organized. And it's interesting to you know you can't use Medigap insurance with Medicare Advantage plans so we're not allowing that predatory relationship to fester because the Medicare Advantage plans were smart enough to ward off that influence. So I think you're slowly but surely seeing us you know whenever you get frustrated with America remember what Winston Churchill said America can always be counted on to do the right thing after she has exhausted all the alternatives. We're just in that process of running through all the alternatives right now. I also tend to remember what HL Menken said which is there was no problem too difficult that a simple solution could become up with that would be totally wrong. So with that I'd like to open it for questions to the audience. Yes Leah and if you would identify yourself that would be great and we have a mic coming. Is it working. Leah Binder from the leap front group the the exchanges are about to come online. We've seen there's been some major problems with a number of states declining to undertake an exchange. I'm really excited about this panel because you actually have not talked about health plans very much at all. And in the past a lot of the discussion around health reform has been really around how are we going to enable health plans to compete. How are we going to ensure the quality of health plans when in fact most of us really care about the quality of care delivered to us directly which is not coming from our health plan. So now coming back to the issue of exchanges and some of the problems we're having right now how would you like to see transparency in the health exchanges. And do you think anything needs to be changed about the plan going forward for undertaking the exchanges. I'd like Marty to catch that one first and then let's go from there. My biggest fear is that people don't have much of a choice right now with their health plan they work for an employer their employer gives them basically one option. And if they don't like that option then it's you're really inconveniencing us and we got to go out of our way and here's a plan that's more expensive. And we can't even tell you what it's about. Last year there were a record number of hospital mergers and acquisitions when the hospital is providing the insurance company. I think we've got to ask ourselves do we have institutions that are too big to fail in Pittsburgh. There's essentially one giant insurer of that area. And when they had an issue with the University of Pittsburgh Medical Center all of a sudden you had 200,000 people who were going to be out of no longer be able to get care where they were going to where they've been getting their care. So that's my biggest concern with the choices that patients have is that as people are afraid of some of the things that might happen in the future given the cost crisis they're just teaming up and we're forming these giant conglomerates. Exchanges have been needlessly politicized. They're based on the federal employee shopping method that's worked great for both parties for 40 years. If there's one thing we can agree on in healthcare it's the relative success of FVHBP. And when even a state like Utah on its own chose to adopt an exchange years ago that's kind of a sign that this isn't a crazy leftist idea. These are all private sector options. But now in this environment after the Supreme Court decision people want a reason to complain about something so some governors have stuck their chests out and tried to make this an issue. It's so disappointing because in the name of states rights they're actually defeating states rights. How does that work? Now I think as a practical matter we don't really know today the difference between a state run exchange and a federally run exchange. It's possible that there's very little difference at all because my guess is that any legitimate private sector insurer will want on the menu whoever is putting together the menu. And the subsidies are going to be basically the same. And so what's the big difference? Now I would like to have more state skin in the game more state acknowledgement of responsibility that the health and safety of their own residents is an important issue. But now it's politically popular in some areas of the country to deny that. But you even have a Mississippi that's stepping up you know hopefully other states will step up. Anyone else? I just have a question for you regarding the politics. I've been a bit puzzled by it because the more states that opt out the larger the federal footprint and the more likely you'll have uniform standards over a much larger area. And that's a form of centralization that I thought was the opposite of what folks wanted. See you're from Massachusetts. What do you know about the way we think down south? It's a crazy thing that economists in the Wall Street Journal have had articles showing that the states that are actually subsidized the most by the federal government are the ones most resentful of federal health. You know if this is human nature people like to bite the hand that's feeding them. One just from a pragmatic standpoint we've already seen with Massachusetts where cost was really kind of the kind of modality for transparency. And in the recent guidance around exchanges certainly you'll still see that as the trend. In order to avoid kind of a race to the bottom where plans are just trying to price themselves you know waiting to see who the early entry into the exchange are what their pricing might be and then just under price them. I think there has to be some aspect of pairing kind of cost and quality or at least and some basic health literacy in how to choose a plan. So Massachusetts did a great job had a lower they had a fewer number of bodies that were uninsured but really used a lot of creative techniques. So I think that adding into what we saw in Massachusetts and with Utah's experience with the exchange kind of some robust way to help show patients. You know there may be reasons you pick a higher cost plan because of fill in the blank and there may be reasons to pick you know the the cheapest plan in your market. And here's what you should know about that. And I'm not sure in any of the CSIO guide you know in any of the guidance from a policy perspective you're not going to see that level of attention and detail. But I think it's groups like yours and a number of us in the room that are going to have to say you know let's absolutely make sure that as people are out there and just thrown into a marketplace which they probably don't understand. They understand how to be kind of savvy shoppers and what that means in the in the health insurance arena. I have a question isn't but but even with the exchanges are we really going to understand what the quality of the care is that's going to be delivered by the different providers. Really the exchanges are telling you about the insurance coverage but are they going to tell you anything about the kind of care you're going to get. Are you going to be able to get shared decision making if you go to X hospital or Y hospital or X doctor or Y doctor. And so so I'm not sure that the exchanges are going to start putting the kind of pressure on the on the providers that they need to that insurers need to put on providers so that payers need to put on providers to get them to start delivering better care for for more efficiently for lower lower cost. Well you're right Shannon we've got a long way to go but the journey of a thousand miles begins with a single step and this is that step. Yeah good questions. Phil if you've got any comments I'd like if you if you have anything Phil I'd love to hear from you and it's best care anywhere is this book about the VA. Yes yes. Oh could you identify yourself. Oh I'm sorry I'm going to get you I'm going to get you next I didn't see you sorry. Thank you so much. My name is Annabelle Fisher I'm a professionally trained licensed clinical social worker born and raised in Baltimore. Very familiar with Hopkins worked at Hopkins and Mass General prior to getting my master's degree. Do not understand why people go to Hopkins because they can find parking there is no parking. No there's a new building now. There never was a reason today so that really kind of blew me away you know you go to Hopkins because it's so well known like you go to Mass General. I had to pick my choice between the right way and the best way I picked the general over Hopkins. But anyway let me get to my question. I loved it working as the general Hopkins has it saying first I want to address two issues. One with regards to the Affordable Care Act to represent of Cooper and it has been raised here is you did not address tort reform. And so patients come to docs and they ask for this test and act test and whatever and until there's some kind of tort reform they write scripts. And I've done everything but a private practice including working with the military. So when they come in and see these ads on TV for psych meds. Hey you know after a couple of times I've got to refer you to the psychiatrist to evaluate whether you need a drug or if you're going to internist a test. And I heard this when I lived in Seattle too. Group health is Virginia Mason's good. So you didn't put in tort reform and can you get that in there because I think this is a real problem. We do need some changes in health care. I'm on Medicare now. So to representative Cooper I have with me a denial from Medicare. They approved the needle but denied the medication to go into the needle. This is absurd for those of us working in health care. We are not surprised. Yes we're absurd. So Medicare isn't that great. Dr. Markey and Dr. Sammy and Dr. Patel I ask you what about alternative medicine. What's wrong with that. A lot of docs are really fighting it but it's can be good health care or working in conjunction with alternative treatment. And then the issue of confidentiality especially in mental health if you're going to have to put everything online. I will tell you most mental health professionals are charting. Are you going to charge me if I'm in private practice. I don't think so. So tort reform Hopkins. Yeah you're good at Hopkins but alternative medicine and the issue of changing that because we're always going to have group people take care of it and just came out in the post. The president is now not eliminating the Medicaid money. So let's let's let's stick to two questions to start because we start to forget the third and the fourth. Thank you. And then representative Cooper if you want to get my Medicare thing that any reporter here anybody wants to do a story. This is absurd absurd. Approve a needle and not the medication. All right. Thank you. So first of all on tort reform I did mention malpractice reform which is the same thing. And then in response to Shannon's question on just say no I mentioned defensive medicine which is another way of talking about it. It's a necessary element of reform needs to be done. I mentioned it twice. Perhaps it was my southern accent. The situation under federal law I'm not allowed to think about it until I get a privacy act form signed by you. So that's the way the rules work on that. So Dr. McCurry and Dr. Dr. Sandy. You know I made a mistake the other day or our hospital made a mistake. We ordered a CAT scan it ended up getting done on the wrong patient. And of course I was worried they're going to come sue me. So I ran over to the patient's bedside and I said you know you were supposed to get a CAT scan today. It didn't happen. I'm going to make sure personally that it gets done before the end of the day. I went over to the other patient's room and I said you know you had a CAT scan today. You maybe didn't know what was going on. It was a mistake. It was intended for somebody else. I'm happy to share the results with you if you like. Now both patients looked at me and said thank you. I really appreciate the honesty. Nobody was angry. People are thirsty for simple honesty in health care. That's what they want. And if we can be honest with people we'll see that the satisfaction the trust. We'll see that divide be bridged and we'll see the tort reform problem be addressed without even trying. Tort reform is I support it. I think it's a critical element. But here's why it's a critical element to remove the issue off the table. That's about it. I think most people have looked at this acknowledged that most cases that should lead to a lawsuit don't. And most cases that lead to a lawsuit really shouldn't have. So there's a big disconnect there. It's also true that honest open communication is really the best antidote. Just as an aside at the lounge group we've been practicing a very conservative style of cardiology for 40 years. And in the management of coronary disease we've not had a single lawsuit. So it's very much about how you engage in that encounter and how you pursue it. I have a simple simple minded question is tort reform something that the states have to do or is it something that the federal government can do. Traditionally tort reform is a state matter. But this is one of these back flips when conservatives want a national centralized big government solution because they want all those state laws overridden. But under traditional federalism it's all state by state. One of the problems is that in the states that have passed tort reform we haven't seen the kinds of we haven't seen necessarily a drop in defensive medicine which is one of the arguments for having tort reform. And I'm not sure that the kind of tort reform that we have so far enacted really really addresses the problem that Dr. Sanny talks about which is that the people who were legitimately harmed do not get compensation. And in fact it may not do the other piece of what malpractice is supposed to be able to do which is to pull out bad doctors and either retrain them or get them out of practice. So it's not doing the two things that it's supposed to do and I'm not sure that we have a very good model out there yet for what would. It's been such an emotional topic it's been hard for policy makers to be rational about it. But Dr. Sanny's right probably need more claims but smaller payouts and then less friction less fewer transaction costs in the system. And in Massachusetts there's a move to adopt the so-called Michigan model which some of you may know about. But essentially when an error or an outcome an unexpected outcome takes place that is related to error there's immediate apology. There's a very rapid resolution potentially with some financial compensation. And in that arrangement satisfaction rates are very high and the actual you know the option of going to a lawsuit remains but actually pursuing a lawsuit drops radically. Sometimes called the I'm sorry model. Yeah. Yes. Next question. Yes. My name is Cooper. I'm with Project 76. I'm taking up on Dr. Patel's mention of Longman who was sitting right here work in context of the exchange question that was raised. It seems to me the I shouldn't say simple but the available solution for addressing many of these problems particularly from a finance point of view is centralization. The premise of his book was to associate every nonprofit provider in the country into one entity. Community hospitals medical schools 10,000 community centers and to use the leverage of that collective to move beyond the provider leg of that table to the supply leg to the information technology leg. To the insurance leg and instead of being on the defensive which is David K. Johnson's Johnston's critique of the good guys in the health care delivery system reform movement being on the defensive. His suggestion is that you go on the offensive the what the forces who oppose reasonable reform of health care delivery systems such that they cut cost and not care to patients. What they fear most is the impossible public option in the government where they could exercise influence to come up the works and where their minions could unfavorably influence the whole. But they would run toward that if they faced in the private not for profit sector a virtual single payer system that using this man's book for providers adding the elements of it insurance supply etc. From a finance point of view the revenue from Medicaid that's being refused the revenue from the exchange movement that's being refused the ordinary cash flow from Medicare etc. If all of that revenue were channeled through this nationwide not for profit health service represented by this guy's book of providers for starters. You'd have the leverage necessary to convince the politicians and industry that their safest option is a public option instead of this truly competitive bohemian you could create in the private nonprofit sector. Can I can I compress that into into a way of for the for the panel to respond to I think what you're saying is is the VA for all a viable possibility is or Medicare for all with with in effect you couldn't you can choose which system you go to. Are those a viable and be would they be better systems. From the private sector. Yes. You can do that. Let's let I'm going to let the I want to let the panel to respond here. I have two reactions. In Boston we can't get to hospitals across the street talking to each other. And I'm sure we're not alone. So I think there's a real problem of how you would work that just sort of culturally. The second issue is really maybe more legal and I'm certainly no lawyer. But you know in Massachusetts with that with the health care law we have. Thank you Governor Romney that there is there's some problems and one of them is that small businesses actually cannot bands together to create the kind of scale and bulk and market power that I think is part of what you're advocating. I certainly think. Lar more leverage on the part of various actors in the system could help rationalize the negotiations but the negotiations will always still be pretty tough. Actually I'd like to let let panelists. There are certainly legal issues with standing so that even in a non for profit setting kind of an aggregation of force of providers that could be used to do exactly what I know the insurer and the UPMC situation kind of modeled out. That would be one problem but you're already seeing something akin to what you're describing by the states that are going forward with exchanges having their Medicaid plan be part of the exchange option. So if you think about it what we're already doing even in this kind of kind of incremental way but in 50 states even one state like California doing something like that has huge effects on the market. You can see a situation where a Medicaid plan which largely would have had vulnerable kind of FQHCs and that's what their provider base is potentially be competitive certainly like Commonwealth Care is in Massachusetts. You can argue about how competitive it is or whether that's the right thing or the wrong thing. But I think what you're describing and Shannon's question of Medicare for all or VA for all I think we're taking that apart in pieces through both the exchanges as well as through the Medicaid expansion. We've been spending a lot of time talking about exchanges. Medicaid will outnumber people enrolled in Medicaid will outnumber people enrolled in Medicare as a result of the expansion and kind of the growing population to childless adults. So which I hate that term but that's how we think about childless adults. But it's it's a very it's so I actually think what you're describing and what Phil has written about is a lot further within reach which is what scares people in some anything that powerful and dramatic can be just as frightening. And I think that's why you see some of this verbal and physical opposition to it. But I think the next 10 years are going to be a fascinating time in terms of moving towards something like you're describing. And it sounds like it's actually threatening to the provider industry. Correct. Because what it means is lower revenue. Exactly. Because again going to this kind of how do we do things with less money less resources and oh wait a minute then we're exposing what kind of you know maybe fat or excess there was in a system. Yeah. Brief. On the question of antitrust and such. There. There are the incentives of finance. For example, a collective group could offer uniform de facto standardized electronic medical records and nationwide health information database. Two providers on a cost free basis including software and equipment if there was a unified effort. You could literally take the health information component financial component out of the budget of not for profit providers. That's one incentive. That's not forcing people together. That's drawing separate enterprises together. Secondly, on the question of savings. Procurement economies of scale matter. If you're buying for every Medicare entity every Medicaid patient. Every private patient participating in an exchange to access this system. The leverage to reduce the cost of supply and equipment for health care delivery significantly. You could be talking two or three hundred billion dollars a year. That's not jump change. So the advantage of the collective is too big a plus to be sideline and Brookings new America and the center for American progress should be sitting down putting your head together with Dr. Berwick. Who this is his approach. This is what he would do if he could. Now we know new America has the expertise. We've seen it here. We've seen it there. Dr. compare. I know she has the expertise. That's Brookings. Center for American progress. They have. I think you've given us. I think it's enough to work for from at this point. So, so I think the point is very interesting. So when a hospital finds a way to reduce the price say of knee replacement does it pass that savings along to its customers who are really its patients. Probably not. It saves that it saves that savings. And that's and that's an increasing. I think that's going to be an increasingly important issue here is who gets to keep the money. As hospitals for example become more efficient as large entities start to be able to bring down the price of things that right now frankly are hugely overpriced. Considering the value that they offer patients who gets that money back right now. We don't have a system that basically shares that with the community that's ultimately paying for the health care. Any comments. At the risk of. Being accused of advocating for return to the cottage industry mentality I guess you know as a as a practitioner. It's deep in my heart. The cottage industry mentality. I'm troubled by some of the scale we're seeing I'm troubled by the fact that increasingly physicians are being employed. You know in large hospital systems and networks and I'm concerned about unintended consequences. So we're currently you know the health care market more I suppose in New England and Massachusetts than elsewhere but it's a very schizophrenic market. We have a real impulse towards global payments both in the private sector with with the blues. Alternate quality care contract which is a form of global payment as well as the moves legislatively and otherwise but. A whole bunch of revenue remains in a fee for service model and in some ways hospital systems themselves are living this kind of schizophrenic existence because. So while there's a lot of potential in ACO is I mean I saw I mean I founded and ran a primary care risk bearing network in the 90s and I've seen that movie and there's certain limits to where you go until you get into the guts of how the system works and really transform it. And that's a slow process but meanwhile the bulking up for ACOs is leading to intended or unintended major market power in these marketplaces and the fee for service side of the business is suddenly subject to forces that are not so good. So scale is a complicated issue at least from where I sit. So I want to end a little bit early but so I'm going to go to Caroline and then to Paul and we have one more. All right. And maybe we want to end early. I'm Dr. Caroline Poplin. I'm a primary care physician. I'm also an attorney. I want to follow up on something you've all sort of touched on that goes to the the story that Dr. McCarrie talked about at the beginning. The person who chose Hopkins because of the parking. In in the future of Medicare of medical care in this country consumers are not going to have very many choices. The way insurers try to save money is to have networks and to restrict the patients to those networks or they pay a very high premium to get out. And we have doctors now working for ACOs that are very large. If you want patients to engage in shared decision making and you spend the time it takes to talk someone out of a procedure like a PSA for instance. They will not trust doctors who they feel have several masters. If they think that you're recommending against a PSA because you're trying to save money for the hospital or save money for the insurance company or you're trying to better your profile. They will be concerned. And if you recommend against a PSA and they get prostate cancer you're screwed. And so is the hospital. And that's happened. There was a federal case about it. So I think you have to factor that in the without the trust the cottage industry part of medicine. It just doesn't work. I think that you're here. I think that your comment stands for itself. Paul Hi Paul Hewitt with the Council for Affordable Health Coverage. Shannon you opened the discussion today with an anecdote about a trillion dollars in debt out there in the hospital sector and the need to downsize capacity to deliver care more efficiently. Sounds like that's a money losing proposition. And I know that the bond markets want to hold hospitals accountable for paying that debt. And more recently I think we've seen some evidence that there's a lot it's triggering a lot of cost shifting. S&P recently released an update of its health care cost indices. And it found for example that the professional commercial cost index in the health sector rose by eight and a half percent in the 12 month through September. Whereas Medicare went at one and a half percent. So we're seeing a growing gap between public and private costs. Medicare and and other payers seek to hold hospitals accountable for their excess volume avoidable emergencies and so forth. It's reducing it's reducing revenues and hospitals have found a way in the current context to raise prices exorbitantly on private payers. We're talking about really two parallel universes. My question here is how do we create accountability on pricing on the private side accountability on pricing on the private side. That is a good question. I thought that's what the magic of the marketplace was for. Just want to make one comment. We have two of my research staff here where this one's a medical student the other's a surgical resident spending a year out of their training just working on quality and safety. We're seeing more and more students and residents saying now that they recognize over treatment and mistakes can harm as many people as we can save with surgery. That's amazing. One of the projects is looking at how many registries we have in health care. There are 200 registries only three make their data available to the public even though the majority are taxpayer funded. If people had access to this information I think you would see hospitals scrambling to be more transparent and trying to have better outcomes providing better value for their business. If you have a private insurance if you call my office and say I need a pancreas transplant we say what insurance company do you have. Oh I've got a private blah blah blah then we've got to go through financial clearance they go through fighting. If you say I'm 67 I have Medicare. Well great just call us when you're in the parking lot and we'll see you down there. There is a competition for patients and I think people just need good information. What do you think Paul it's good information going to be enough. My guess is that we're going to need some sort of mechanism for better price discipline on the private side that matches something that we have on the Medicare side. But if we just tap down on Medicare costs we're going to result in a ballooning of private costs that eventually creates access problems for beneficiaries. So do you see that as having a legislative solution a regulatory solution a state level solution a federal solution. I mean what are the what are the possible what's the range of possibility here to start to. Right well there are a number of administrative solutions you could pursue at the state or the federal levels. Some have suggested all payer where there's no price discrimination at all everybody pays the same price and it's negotiated once a year. My sense is it might be most effective handled at the local level. But if to the extent that that market concentration and you have a situation where 90% of hospital markets are highly concentrated according to FTC standards where that frustrates real price discipline. We have we have mechanisms everything from utilities to antitrust to deal with that kind of issue. All right we have last question you have the ultimate question. Hi I'm Susan Huffless I am a researcher at Johns Hopkins University. I'm not a health care provider and it seems like there's this underlying trend that there's a disconnect between the patients and the provider and what information they use to make health care choices. There also seems to be this hint that the solution is education for the patients and if only the patient could be more educated there would be a solution here. I wonder if there's something that the physicians could do to help close that gap and if you guys agree that that should happen. I'm also a little concerned that the answer might be that physicians just need to be more honest and if that so how do we educate physicians to be more honest. I don't think the answer is just patients need to be better educated putting some sort of burden of proof on them. That's not how at least I don't think any of us were saying this needs to be patient. I think if anything it's that there needs to be transparency because it does two things. It helps to first of all give information and have it out there whether patients use it or families whomever needs to use it researchers such as yourself as well as it puts a little bit of fire under especially doctors. We know doctors respond very well when things are posted and you're compared across each other in the practice and people say well how come you were so bad at giving pap smears to your patients this year. What was it about how you know what you're doing that makes you so bad at this and that's certainly an incentive that physicians in particular respond to time and time again. In terms of getting doctors to be more honest I mean I think Marty was born this way. I think he's always going to be this way. I don't think it matters where he works or what he does or whether he became a surgeon. I think that in some level we're imprinted upon just the way we've you know whether you believe this kind of philosophy or not. I think we practice in many ways based upon our own just kind of personalities and attitudes Jerome Groupman writes about this all the time that so much of it is just subjective based on how we think. So I think what has to happen is not necessarily you know let's just tell all doctors to be more honest but it's got to be kind of multi-pronged. Professions need to own back their people we need to we're no longer really a society physicians don't really have a we don't really have a professional kind of cohesion amongst ourselves. We're all out there on our own for most part we need to kind of come back as a professional practice. We need policies such as kind of the things that we've already talked about around tort reforms and helping to put things down so that doctors feel like they can say no. And that they're not going to immediately have somebody calling somebody even if that's just a false mental belief we need some way of having that. And then third we need to have cross specialty communication. It's very rare that I can get my surgical and cardiology colleagues to actually return any of my calls or interact with me about any of my patients. So we need to have a little bit more humanism just amongst ourselves and that's that's at least a better place to start than just give patients more information. Great. Well on that note I think we'll end and I want to thank all of my panelists here.