 So I've got to rush because I'm at the end here and we're late But those two presentations from my colleagues were just terrific and they really have laid down I think the groundwork, so I've got a let me just try to pick up and emphasize a few points here and there as I piece through it The one thing that they through their demeanor did that I like and it is somewhat In response to the questions is that we have to work together And so I what I like about this meeting is that we create the the the template for Conversation there is nothing that we are talking about that is easy This is all hard stuff and it can get emotional ain't it get very ugly quick So at the end of the day if we can't have the conversation in rooms like this We're going to be in big trouble because at the end of the day we really are all in it together I don't know whether I understood the eGap slide, but It's for my what I'm seeing is we're getting past the point of genetic exceptionalism genetics is medicine it's in the game and so I'll learn from you later why I need to be careful about saying it but By my way of thinking we are at the point now We're you know, it's we're talking about medicine and I think that becomes sort of for me very important Implementing it then provides Opportunities as well as it does challenges So both of my colleagues talked a little bit about costs and I want to just make sure you really get costs Really get it if you don't get it in the way that you I mean in your DNA get it You're going to be off in outer space and you are going to miss it These curves on the left and the top to represent Physician and hospital-directed care delivery the slope of those curves is breathtaking This is where the money is Physician and hospital-directed care the other ones durable medical equipment pharmacy and all that kind of stuff But the action is here and that's how you get to 2.5 trillion dollars of expenditure What's scary is the right side and that is looking from today out and look at the top two curves again And it doesn't take but our heartbeat before you get to 4.3 trillion that can not happen it will not happen and so If you look at it only from the point of view of just Medicare and Medicaid This was the been the cost curve slide when President Bush the second was in office And he says we got a problem legion with Social Security here in America and the Congressional Budget Office The Congressional Budget Office said look here dude, you ain't got a Social Security problem You got a Medicare and Medicaid problem that curve is going to get hammered Hammered down like you cannot believe and it will not be surgical and There's no state by the way in this country not one state that's got any budget relief And it's not going to be in deep doo-doo because of Medicaid So they're in deep doo-doo. The only place you can off shift costs left is to the consumer And the consumer out-of-pocket costs looks like that and wages look like that And there is nobody in this room that believes that wages are going to go up. So it's over Now the highest component of escalation in cost is not utilization It's unit costs the price of things So all of you that are involved with companies that make stuff Pay attention unit costs are the highest escalation in health care number two Health care is complicated as hell already without you and as my colleagues said Half the time inconsistent with the best science. And so these folks are in deep doo-doo 2001 there was the crossing the quality cares and report if you have not read the theology of the redesign of health care in America You need to go back and look at the at least the executive summary Because it was very clear about what had to happen and what has to happen is Everybody knows the mantra of safe effective timely efficient Equitable patient-centered, but the rules for redesign continue evidence-based decision-making continuous decrease of waste Anticipation of needs patient a source of control all of that undergirded by shared knowledge and free flow of Information so there's all this stuff Pouring into the delivery system every day Bust in the bank and making everyone crazy and the assets being pissed away half the time and then We get you and this is what We see as the scope of that curve So yes, everybody's talked about how many tests and you know the the sense of it our estimates are Between three and four billion in spending from 2006 to nine But then by doing some calculations that we're pretty confident about and that we have published and put into the public domain We sort of see that national spending will reach Reached five billion in 2010 eight percent of national spending on clinical lab And we believe that today while it accounts for a fairly small amount of a twenty billion dollar in vitro diagnostic market that we believe that Spending has grown substantially over the last ten years with the annual growth rate of an estimated 12 to 15 percent Rates much higher than for clinical laboratory services as a whole and with these scenarios we project That molecular diagnostics will reach between 15 and 25 billion by 20. We talking now real money Real dollars real stuff no plan around for our company alone 500 million in 2010 Because you gotta remember now the size and scale of a company the size of United Health Care and United Health Group and spending per member Increased by about 14 percent a year on average between 28 and 2010 And this is what really worries us the volume of all of that and the pace of discovery Increasing the complexity of medical decision-making so human if you think about the facts per decision Around the company in the growing complexity of the genomic movement and the thing in the red is flat human cognitive capability So can you imagine what is about to happen to the expenditures in health care for your stuff? Tomorrow and what it means to this country overall Now having said that let me address the question. It just came up We love innovation The problem that we have if you look at it from a entrenched narrow Managed care world is every new thing and you heard it two presentations ago Every new thing in health care costs more than the old thing the only industry where that weirdness occurs You can't buy a thumb drive anymore. They just give it to you when you go into the store, you know memory You know like man, I can buy a hundred megabytes of memory and it's like three dollars and twenty-two cents What goes on in the rest of industry but in medicine every time we see something new the price is higher and It gets we don't know who it's appropriate for so you don't have we have a real hard time Figuring out who you apply it to and then when we do have guidance We piss it away half the time inconsistent with the guidance. So when we see new stuff, we usually go running down the hallway screaming Which is not the place to be Because what you really want is to find things that are going to take costs out of the system and improve overall quality In fact, I said it wrong bad me. I Violated the theology what we are looking for is innovation that improves quality and that takes cost out of the system Because it's quality first always and cost decrease second So that's what we're looking for and we do need to be on a seek and find mission to find those things that are going to do It and so we look for innovation So how do we think about innovation? First of all know this Innovation for innovation sake is meaningless. I could care less That you got three more bells and two more whistles than the other guy. It means nothing to me Just because it's new is worth nothing Does it disruptively replace more expensive and less effective traditional interventions? Is it new value propositions improved performance based on new performance criteria my cell phone my smartphone? It beats the hell out of phones because I don't even care that it's a phone Whole new value proposition. Does it optimize health outcomes? Does it make preventive and clinical care simpler and less complex to deliver and more convenient? Does it most important move hospital care to the outpatient outpatient to the home and to the community? Now we're talking we can do some stuff like that. We got a chance To do it So we want to support new breakthroughs in health care true breakthroughs in health care rare Usually they're incremental Additive and so the new imaging procedure comes you add it to the old one And then you get a discrepancy between the new one and the old one Then you do a third one and then a fourth one the next thing you know We're all in deep trouble. So what you want is is things that are that that can you don't want halfway technologies You want to get straight through To the source of the problem to the root causes so we like the idea that genetics is going to offer that Possibility cut through the crap get to the source Eliminate the halfway stuff and you've got an opportunity to go for it. So to us it does make sense The issue though is left to its own devices The world will not give us the information that we need to be able to know when we have it So all that conversation about comparative effectiveness research and all that my colleagues have laid the groundwork and my friend Sean who thinks clearly about it and by the way Sean's work is supported by the health plans In addition to other stakeholders. So I write a check So does that know we write checks to Sean because those things that Sean is doing is important So don't get leave thinking. Oh, we don't put our money where our mouth is. Oh that we're not invested in this stuff We absolutely are invested in it We have to know whether the new thing works Does it work better than the old thing and if it is better is the better Justified the price escalation. That's the question and there's nothing wrong with asking it And I'm not going to ever let somebody make me feel nervous About asking that question because I sit every day With small business owners who mortgage their house two and three and four times to make a go of it employing five people Tenuously watching their health care costs go through the roof because of all the nonsense is out here Why should they pay for stuff that doesn't work or doesn't work? Well in the total cost of care. So we have to know it. It's the responsible thing and yes There's rationing and the rationing is on the backs of pregnant women in inner cities Who don't get first trimester prenatal care and their babies die worse than 50 other countries in the world? We ration all kinds of stuff and nobody gets pissed off about it So we got some issues to do as a community the reason why I'm being so forceful about it is this if you are a business model If your purpose for doing what you are doing is to keep trying to game the system Then yeah, health companies like ours are going to be some mean sons of guns and we're going to hold you Accountable and we're going to watch you and we're going to be really cautious And is that a good reason to go to work every morning? It absolutely is not what we want are people that start out with Let's do it right. Let's do it better Let's find the answers to these things and then you will find willing partners now the reason why Sean is so important is After I give a talk like this, they'll maybe it's like 35 I go to these meetings with all the innovators and the startups and people that are gambling Their money would vent your capital You get 30 those people going okay. I want to do comparative effectiveness with research with you I want to answer these kind of questions. I really want to get there now What is the exam questions you're going to ask us and we could spend every day of our lives all Day answering questions about what is the gold standard for what we need? And we don't have that kind of time because we are trying to run our businesses So Sean I think in his company is going to be very very important as a place for people to go So what I want then I'll say it in front of my colleagues from the blues from Edna What I really hope and we have to be careful about conflict of the the lawyers and the thing I'm not talking about what we're going to pay for anything For the record don't care about what we're going to pay for how much money we're going to reimbra I'm not trying to price fix. I'm not going off to jail But what I am saying is why don't we and that's what I think Sean's organization should become in my opinion the place where the plans increasingly say FDA criteria necessary, but not sufficient not interested Thank you. Glad you're not killing anybody But the extra hurdle of comparative effectiveness research Here's what we want in terms of the questions that have to be answered just because your new hip Articulation moves three degrees more than the Owen does anybody care because is it functioning significant or not? So that extra ingredient whatever it is that we're looking for we all say to the into the researchers the manufacturers Here's what we want now go program to that so you don't have to do but one time And I think that's the way we sort of get at some of what you're trying to get to Well, we have real problems in trying to develop that evidence to tell our customers now our customers are paying the bill They are expecting somebody to watch out for their interests And we don't have the information that we need as we've said a hundred times to do it So randomized controlled trials versus coverage evidence development These are really tough issues and I don't have time to go through those anymore But the bottom line here is that the key to any effort is broader use of analytics that can identify Where the diagnosis can reduce downstream medical costs and improve health outcomes So I'm talking about the total cost of care and the big picture and then finally The people who use these tools are Going to also be changing fee for service is going to die Understand it nobody can keep paying piecemeal for crap It isn't going to survive it can't and it damn sure can't happen for the people you care the most about is your referral network And that's the primary care doctors the primary care doctors are done. There's no money for them They're not making any money Nobody goes in the primary care The only way primary care is going to survive is if they are able to take Responsibility for a population of people provide better quality more cost-effective care take the savings have the savings Reprogram and pour it back into them for salary because nobody can write a check to primary care doctors because the unit costs and that costs escalation There ain't no more money the party's over. Well, guess what the primary care doctor is going to look for the specialist and say now look here It becomes patently clear that this laboratory costs twice as much as the other laboratory and my criteria I'm being judged my scorecard says I'm out of whack and my cost and reimbursement is going to affect So why would I go to the highest cost lab when I need to go to a lower cost lab? This deal can keep quality whole why would I go to a specialist that screws around in orders 15 more imaging procedures That didn't need to be done. Why can't I go to a professional who can't schedule my appointment for my patient the same day? Why can't I get 24 hour coverage? There's going to be a whole nother Realignment of specialty care downstream to solve and serve the primary care people who are going to be back in the Driver's seat with a lot more control So you are starting to think what is my relationship as genetic Degeneric providers to the primary care delivery system and also in terms of how I'm going to be reimbursed for managing a population of people Who have a predominance of genetic-based disease this reimbursement model will increasingly be moving from fee for service to Accountable and will move people from solo and three and five practitioners to groups either real or virtual But there will be changes and modifications across the board and then finally finally After you've pleaded beg Given people information done everything you can do Got the control at the end of the day You still got to do as my my colleague just mentioned you got to do medical management because left to its own devices people will piss away half the Time so unfortunately, we still have to go to work and go. Why did you order the 18th MRI on that lady? Did you really need to do that? I mean and that's just something I wish we didn't have to do But we have to do we have to align all the incentives. So I know I've irritated like everybody in the room But out so I will just sort of end with this This sort of sense and we'll take and then I'll be part of the group to take the questions if there is time We need you to be successful it is exceedingly important that you succeed But you're not special in Many ways you are part of an engine that is completely Churning and moving and growing at rates that just cannot be sustained It has to be new models where you are special is at your highest You have the potential to solve problems that most disciplines cannot because you're not halfway Technologists you're cutting through the crap get into the source of problems and can eliminate it Your job is to figure out how to bring those to the delivery system in Responsible ways so that you can save money and enjoy the savings and make money that way But if you have business models that are based on Marcus. Well, be error thinking you will not make it You will have enemies you will have people that will be holding you down and watching you and at the end of the day You will screw up your access to venture capital, which is the one thing you do not want to do health plans like us Etna blues we want venture capital to love you because it is important that innovation succeed So do it the right way do it for the right reasons and you'll have partners don't make enemies out of us because we love you Is that do we say here end at the lesson is that the way? Let's say here into the lesson. Yeah, so Michael, you know, and I know you know, I'm the last person in this room We should say that but that's the one Michael one thing that hasn't come up is that the cost of the test Might in some part even to a great part be completely outside of health care and people will be coming with the results to doctors and the health care systems and The downstream costs might make those testing costs look tiny so I would propose that we have a work group that Collaborates with industry and others to to really look at downstream cost as well as cost of testing I think this should be a work group anyway That gets it because as I said, it's so important that we be aligned you we have to be friends We just have to be but in terms of that I really like your point because what you're saying is in reality there are going to be a bunch of people that still want to know whether they're baby gonna have blue eyes or not and They're going to go offline and do whatever the heck they want to do And they're going to be people they're going to you know have and so you're right how you then what what do you'd wind up with? When you get your Nutrogenics for the new Millennium Test and you walk into the Doc's office and what is the responsibility of physician has to work that up with 18 MRI scans? And how does that get paid for I think you're just your question is just spot on mark We can make the case that a whole genome for two thousand dollars You know instead of doing a blockbuster test would be a way to go and start doing that right now because then you could Start to model Dave's question of how does that bring down overall costs knowing about the whole genome? Yeah, so so I think that's sort of again the notion of That kind of sort of big picture thinking so if I understand your question is Does it make sense overall to and of course I don't know how you figure it out But if I understand your question, do we basically make a national investment in doing the entire genome sequencing for every person one time? Store it make multiple access to it under rules and provisions of privacy and confidentiality I don't know and then basically it's there and then people can sort of fool with it or not And what's the cost effectiveness of that and and what are the costs of storing it? What's the course of accessing it and a health information exchanges and blah blah blah blah? But it's least it's a question that needs to be asked and it needs to be a question needs to be answered Mark retain Chicago. I mean I think that genomics is different in many ways and Well, we it keeps getting lumped under it keeps getting lumped under diagnostics and as I mean, I'm a practicing oncologist I'm very familiar with the waste and abuse and the patients I see Referred in from the outside to see us at the University of Chicago after they've been treated in the community with three trillion drugs that don't work and seven seven thousand MRIs and Every diagnostic you can think of and clear approved clear laboratories and even some FDA approved Diagnostics and I and I cringe every Wednesday afternoon when I go to clinic. So But I think the point is we don't need to be spending the kind of money that is currently being charged per Polymorphism in laboratories. I mean to go and order a single snip A one-off snip is I don't know what list prices are these days But that you know, I usually say it's somewhere between five hundred and a thousand dollars list price for most Clear laboratories. I don't know Deborah can can comment what what goes on at her place But you you look at the Mayo website and that's crazy and and if you use those kind of estimates Of course you come up with figures that are just completely unmanageable when you start looking at genomics, but We don't need to be doing that and we should be we absolutely should be thinking of ways to implement genomics in a cost-effective manner and whether it's whole genome sequencing or its platforms to identify that they utilize Polymorphisms of clinical relevance to really do it en masse where you can drive the cost to pennies Per variant I think really allows this field to move forward in a way that is truly different And I keep coming back to the EMR because that's sort of an investment for the future that people have accepted And I don't understand why we're not thinking about how genomics can can be a whole new system Yeah, I guess I have a question which is I want to pick up on the themes of Alignment of incentives and partnerships and one of the reasons we're having these meetings is so that we could develop the The right research agenda that will enable us to really realize the vision of NHG rice You know strategic plan, so so I'm we're looking for people like you the payers to help us find our way and I'm wondering whether there's a real possibility of partnering In helping us design our studies with the appropriate metrics and funding them So that they will actually get done in a timely fashion so that it will actually benefit the whole ecosystem that you spoke of And make available data that you have that we don't I would Assume my colleagues think but that's what I was sort of again I'll just re-emphasize even though it is not a fully formed proposal yet But but one that we have been talking about and I think that I don't I don't like recreating the wheel with creating new Institutions and new organizations I came here today along with my colleagues because we believe that this is an important forum that deserves our energy I think that what Sean's group is trying to do is a wonderful place because it's it's it's where both the Manufacturers the innovators are sitting and the plans are sitting together And so I would say that just with an interest of time that your suggestion to me sounds terrific I think that's that we ought to try to at least use Sean's House as a place to get together and and fool around with this a little bit and do it in a hurry That's my proposal with it And I'm going to be talking more to my colleagues to see whether or not that that that dog will hunt I'm sorry. I forgot your name. It's a mark right so You know, I was just going to try to reemphasize I mean, I think you're asking a critically important question which You know around this issue of You know the ways in which genetics is different and you've described it But you know the possibility that you're going to get you know Thousands of snips or hundreds of thousands or whatever at a ridiculously low cost compared to these you know 21 sequence tests or whatever and so I mean I and I think that Offers the possibility that you know, there would be extraordinary ways to accomplish what Reed said, which is You know better outcomes for patients that dramatically lower costs like huge and I think that's the exciting You know opportunity what I think the way in which this technology is kind of the same in terms of what I heard at Medicare and I think what all the other payers here is Just pay for us now and we guarantee you you're going to save billions, you know down the road and and that the You know, I would say that you know if if we actually saved one tenth of what was ever promised to me in a day at Medicare You know, we wouldn't the Medicare Medicaid thing would not be an issue But so that the real question is at what point do we sort of cross the threshold? between wanting to believe that this will happen that this can happen and sort of You know being confident enough that we're you know sort of willing to make that investment because you know what I'm saying And so it's sort of defining How do we make that happen where it isn't you know a Attempting offer, but we just you know, it's it's like every other offer that says, you know Pay us now and you can't believe how great the world will be you know in the very near future And I would just say that every technology company that comes in front of us comes with an economic model With assumptions of grandeur and it never happens. It just it just doesn't happen Yeah But that wasn't my question My question actually was to the laboratory folks we talk about you know disruptive technologies and one of those may be Multiple appropriate snips on a chip that can bring dramatically drop dramatically the price of the diagnostics How does the laboratory business model fit into that? I mean, are you excited about a new technology that decreases your reimbursements dramatically? I think that we're we recognize the same thing that everybody else recognizes that the curve on health care expenditures is unsustainable to us to you to everybody else and so to the extent that we can participate in developing Tools that would lead the industry in cost-saving or more efficient delivery of care We are absolutely on board and we actually are working on a number of initiatives to do some of Exactly what you're saying in other words where we can combine things together and actually offer them at a lower cost Where we can provide decision support tools that help the doctor order the right test at the right time There's a number of initiatives on going at lab core to support that Oh Sorry, I'll tell you later. I Guess I was just gonna bring up the the the concept when we were talking about people coming in I with Tests from the outside. I mean we don't even have standards for that. I mean people do it now for genome-wide arrays that they can buy on the street and they get these reports Maybe not anymore but some of them probably still have some old ones and they come walking in with these things and want to know what this means and I think more importantly in cancer. I think there are many providers outside of the arena that's sitting in this room that Are gonna provide people and they're gonna buy it off the street a cancer test and Because they believe this is there You know, this is what they need and I think that we are gonna have to think about those downstream costs when they come in with those tests that We don't have access to necessarily all the primary data So to speak to Joanne's question about the diagnostic tests, you know if I look at our one of our Disease panel tests hyper-trafford cardiomyopathy the cost for that test has not dropped at all in the eight years We've been doing it, but the content has increased So we've increasingly multiplexed from two genes to now 46 genes but not raised the price of the test So even though the test cost hasn't been dropping We've been able to add content over the years And and that's where we save and from a business argument as a lab laboratory We often compete on content between labs and so we're constantly trying to add content to outcompete our Competitors in terms of a better test But but if we look at to the question of scaling to the genome because there's a lot of Efficiency to be saved by getting multiple markers in the same test You know, I love the email Mike sent me sent us a few minutes ago a whole genome should should actually be whole genome without the W-h-o-l-e Because there's still so many holes in it And I would argue if we implement whole with the H genome sequencing today There's so many holes that we will have to Reflex on to the targeted test after the genomic test is either Uninterpretable or negative and so you you haven't yet saved that cost We eventually will get there when the W gets added into the to the you know the picture So Mary I don't I don't want to stop this discussion Mary David Deborah I Guess I just wanted to be sure, you know There's something in between single gene tests and whole exome or whole genome tests and and so there are several arrays like that so is Just to clarify from the payers is the concern about running an array for 225 genes that costs less than a single gene test that medical care costs will go up in general because Clinicians will work up additional findings from those 225 genes that they wouldn't have otherwise had you only given them one test result I mean what you say that you think we're you know, you've been hoodwinked before Being sold that things will save money in the long run But it's very hard for us to understand Why should we test for only one gene at a time when we definitely have some? Array-based technology that can test for at least hundreds of genes at least as well for a fraction of the cost Yeah, I think it's an area under development number one I would say my first reaction is we cover things where the medical evidence is strong and and the society say you should do This so I'm thinking I know, you know my area's reproductive genetics So you would say we had this discussion last night, you know if for Ashkenazi Jewish screening ACOG says for mutations ACMG says 11 or 13 or something Genzyme does it, you know, whatever What's the right answer? So the first question is you know, we were out there saying that we're trying to support But what would be the downside of having a test that covers all of those plus more Okay, so maybe an Ashkenazi Jewish populations no downsize Side I'm thinking of you know the hundred genes on a chip that were just direct started as a direct-to-consumer The council technology specifically that now is put in reproductive endocrinology IVF offices These physicians are interpreting this they're getting results on Maybe one thing they wanted a CF test 99 things they never heard of before and then it's turning through this It's either ignoring things that are potentially important turning services through the system And I think we just don't know what to do with that What we were talking about the radiology example what what I was actually reminded of is you know Medical school 101 lesson, which is if you are interested in pathology in the chest You aim the x-ray technologies at the chest you sketch your hands lapped if you actually looked at the appendix or the gallbladder Something else sometimes you'll find disease there and you'll say God wasn't I lucky But often you're finding things that you don't you didn't anticipate you don't know what they mean You know you've got these variants of unknown significance, etc. And those things Turn through the system. So I think this is what we're They do take money to work up for sure they take money to work up. So Let's let quick comments and let's keep this discussion. Oh, Deborah I Think it's interesting that Johnny you pointed out that the testing costs are only point less than point five percent of Overall health care costs. So I think when we look at Testing the testing costs are actually a very small portion of the health care cost They drive a lot of the decisions medical decisions and I think what we have to be talking about what you guys have to be talking about I'm not part of this but is is how you do genomic medicine and and so it's how This testing fits into the entire pathway of patient care And what makes sense and is useful to test for because there's something actionable that can be done Versus the discovery part that should be research and not part of Genomic medicine It's genomic medicine research, but not part of the health system and health care process and In my small project that I've pilot project that I've been approved to do with hospital funding is Is looking at an entire care pathway from how we identify the patients and enroll them and consent them and All the way through to how you know we do the testing, but then how that information is communicated back What decisions we would make having genomic case conferences? I mean the whole Entire pathway and only testing for the things that would be Clinically actionable potentially, and I think that's where we have to Get to Please yeah It's a very great question and point but and and into the question before Please don't misinterpret anything that that Naomi join our are saying is drawing lines in the sand Just cuz something is expensive first of all does not make us nervous It's the total cost of care as I tried to say in my presentation that we are interested in Naomi I thought did a very good job of of showing for example the number of times where a Diagnostic test is Decoupled in terms of its behavior with the therapeutics that's based upon the presence of what the diagnostic test would show We love a test that is even if it's expensive Diagnostically that will allow us to titrate the appropriate Subpopulation for whom a therapeutic is involved fine. We give away darn near expensive chemotherapy drugs for leukemia We subsidize them because the total cost of care means that that patient is not going to be in the ER is not going to have Hospitalizations will decrease read missions and all in it's less so there's nothing that scares us About costliness it's if it's justified So I just want to make sure that we don't argue that kind of thing out And then what you get to I think is both of these questions is being clear about the particular Clinical paradigm that is under discussion and making sure that we understand that so we do know we are agnostic to To to you know, we're not trying to draw these major lines and say oh my god. No no no Case by case specific by specific now. That's where the problem lies is the Capacity of the American comparative effectiveness research engine not to mention our clinical Research engine to answer the plethora of questions that are on board and that's why Naomi if I understand her presentation Why she decides to include the things she did Included what was on the list that came out of the IOM and what's on the list for PCORI to get looked at And she's sort of saying listen folks Is there a relationship between the priorities of the research enterprise and the fundamental Clinical questions that are the most determinant from a quality and cost effectiveness point of view So those are challenges that you're going to need to be active in so we hope that you will be attentive to that because you can't answer everything all the time David Okay, you're just take a Take a chip for later Yeah, I wanted to This urban again wanted to second Deborah statement about I think the discussion has been focused Very much on cost of snips and tests and all that but I think what we really need is help in determining the value Not so much the cost. I think you know and thinking of it in terms of there needs to be research First that ties this into care pathways and has the whole game for this pathway the whole picture for a pathway You know at the S as an outcome at at the end and and that the question is value Not so much that the snips are cheap and the genome is a thousand dollars But what value do we get out of it and then we can make a case for our community to be accepted I want to come back to a point that Jeff Ginsburg was making about Engagement with the payers and we talked a little bit about those that back in December at the vote those you do that were at the meeting But they're certainly in our little experience with Blue Cross Blue Shield North Carolina when we talked about end points that they care about There was a little bit of overlap with academic end points, but not a lot And we've done a study with them where we have an MOU in place where if we meet the end points that they chose They will implement it across the state if we don't we'll shut up and not ask them to do it again And I think we need to do more of that where we partner where the endpoint is decisive At least for the moment decisive information where we can either Be quiet or have it implemented and you're right now we we play around that But I think we need your partnership for that we need some of your money But we need more your choice of end points because I never thought Adherence at the end of one year for statins was an endpoint that I would ever care about But Blue Cross Blue Shield not only cared about it, but they're willing to pay for it So you know, there's there's things there that we just don't we don't recognize As usual my opinions represent just my opinion and not the Air Force or the Department of Defense So I just wanted to issue the same two challenges that are my usual personal crusade and that is Using international standards to measure value in this country, which would be quality adjusted life years not American dollars and then the second one has to do with the fact that What we're talking about why I asked myself why on God's green earth am I in this job? And that's because what we're talking about is culture change This is a paradigm shift if we continue to talk about why this doesn't make sense when we are Western trained physicians And we label disease and treat it without looking at the underlying cause We're going to continue to have the same debates over and over again Because looking at the genetic basis of disease is something that is in theory looking at the underlying cause not what we're necessarily trying to do as MDs or DOs so Thank you While we all beat up on the healthcare system and the practicality of it not being able to continue the way it is It is and it's picking up on the last speaker's comment something between 1960 and the present has changed life expectancy from just about 60 to something about 80 and the health care system and everybody involved in it is partially responsible for that As a follow-up question, I'd be interested in the perspective of the third-party payers on the new data that Suggests the de novo mutation in the conditions of autism Schizophrenia and mental retardation is looks like it's Compellingly clinically useful. There's no FDA approval. There's no Clinical tests that you can actually get for that, but it looks like the data that's recently published is overwhelmingly compelling that these conditions I Don't want to get drawn into or have any impression left of artificial tussles We are in no way. Are we arguing about? Well, you first of all ain't no way are we arguing? But again, what we are definitely not arguing about is how terrific the American medical care delivery system is I am I serve on the head of NIH's advisory committee I am very proud of the American biomedical and research community I am the former doc for the AMA. I am very proud of American medicine There's anybody up here talking about not being happy about the the FNAB fantabulously wonderful benefits of the of our clinical care delivery system, however Let's make no mistake. Our life expectancy is 40 second in the world and we and and we pay Orders of magnitude more in health care than any of the other countries that are better than us 41 times So there is an American Conversation that has to occur about how and where we use our precious health care assets That is unavoidable for a mature civilized democracy So we do have some tough issues to deal with but at the end of the day We let's just be all in amen on the fact that yes, nobody's here trying to say we're not doing a good job In terms of the things we do now in terms of what I really like though is your last comment Which gets to this point that we would least that we've been all three of us trying to make around cut through halfway Stuff and get to the root cause so if your autism example is true You know and it's there and we can get at that and understand that better Because the last thing that I want to do as a person who has to make decisions about using dollars That are hard earned by American workers The last thing I want to do is give them an inadequate treatment for a disease That we don't understand and they can be better proven because anybody has had to deal with the development of the disabled world And I've run major systems of care for the development disabled I understand that world real well so at the end of the day if we can get some stuff that cuts through and helps us You'd be out of your mind not to want it now the issue then you raise is okay How do we among the 50? Priorities that we have in this country to get to root cause stuff that we're to really in it where does autism fit in it? What is the role of health plans who have to spend hard-earned employers dollars to be able to say we're gonna You know put that dollars to this one and not this one and this one and not that one How does that fit into the PCORI with the national re these are the kind of issues that a forum like this has to think about? In your profession and then be prepared to discuss it with those who are outside of your field so that we can come to some Priority decisions around the research enterprise because guess what by the way they ain't doobly squat Clinical researchers around anymore and when you finally get those then you got to worry about the people that are gonna do The cost effectiveness stuff. Oh by the way, then you got to do the health services research Oh by the way somebody's got to turn it into clinical guidance. Oh by the way somebody's got to do Performance measurement. So what did we just do to the workforce for research and all of that? So priority priority priority, and I'm not saying your priority is wrong. I'm just saying how do you have that conversation? So Paul Rittger has been waiting patiently Last comment quick comment Paul. So I'm gonna choose my words extremely carefully for a second here And party cuz I have a conflict of interest but more because of a bigger issue. I think so so Naomi Joanne and Reid have argued among other things that they Would favor potentially expensive diagnostic tests If it might actually limit therapy Or get to the right people I? Think that's probably correct my experience in the diagnostic industry and the payers is That you also fear diagnostic tests if they expand therapy and This has to do with my own technology and issues about how hard it was to get certain companies to Pay for CRP testing even though we had randomized trials showing you could save lives and lower event rates That includes United Health Care, which is a huge battle So I think this is another side of this which is we have to ask questions about even when overwhelming evidence exists There's tremendous resistance to wanting to change And I think that's also a part of what Shawn has to struggle with but we can talk about that We can have a an hour-long discussion. I think we'll Because there's no need for for us to be at least speak for me And I'll see my colleagues disagree for us to be defensive. Is it possible that we make mistakes? Is it possible we are wrong sometimes? Is it possible that you know we make the wrong choice? Absolutely, and do we need to change that's why I said and I was very transparent So I will agree with you because it's important that we find common ground here as opposed to leaving Because the point the only point of all this could be has to be we keep working together So at the end of the day I said we do go run down the hallway screaming when somebody tells me I got three more bells and two whistles We do do that that is our behavior, and I also am saying deliberately to you. We're trying to stop doing that dumb stuff So we're trying to be different. So I accept your premise and if we were wrong, I apologize The other thing that I would add to it is that we cover thousands and thousands of things and those things require hundreds and hundreds and hundreds of technology assessment Conversations deliberations interactions with the technology people It is sometimes hard to get eight and I don't know the example that you're talking about But it's sometimes hard to get the attention of a large organization It is very helpful to get technology assessments done through the medical professional colleges CMPT others that can help synthesize it e-gap That sort of gets to a higher level of attention and organization and quicker decision making I don't know the example that you're speaking of but so I will I'm the chairman I'm going to stop I'm going to say one thing if the autism example is true, then it's just one of illustration of the real promise of this kind of new technology which has been around for Years not decades. And so we're this is the beginning of a long conversation And we will resume in 11 minutes My computer says it's 3 39 so we'll start again at 10 to 4