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tv   Health Care Policy Part 2  CSPAN  January 13, 2017 10:28am-12:09pm EST

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thank you all for coming act after the break and finding a seat. we appreciate it. go ahead and get settled again. i'm the ceo of the pacific is in this group on health. some of the panelists you've just heard from our members of hours. let me say a word about what we are doing here. my job is to really help make a transition between the wonderful case studies and insulate you heard from employers and purchasers to the implications for policy development here in washington where we started the day and where the next panel will take us into quite a bit more detail. first i want to thank aei and
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brookings for sponsoring this meeting for us. it's a tremendous opportunity to have a dialogue that's nonpartisan and across many points of view to think through what are the successful developments in healthcare policy. one of the sponsors, we represent 60 large employers and purchasers. together they have about 12 million covered lives and they spend about $60 billion every year. they have a strong stake in the improvement of the health care system for their own population and several panel members. it's important to know that while these are tremendous organizations that are investing a great deal of innovation, experimentation and learning, they are not typical of american employers and there are many small and medium-sized employers around the country who don't have the resources or the scale to influence health care as directly as some of these companies can. i think one thing we will talk about are the implications for these strategies for other
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employers who face many of the same challenges but don't have the resources to affect the market. certainly we think there is a lot to be learned from the lesson of the work that they have done. what i want to do is take a minute in transition between the first panel and the second and mention a few of the themes that i think we've heard and we need to come back to as we talk about implications for the market as a whole and for public policy development. first, there are lessons. most of the topics you have heard described today have a mere image image in public policy in the current discussion, in aco development and ach design. we want to have a dialogue between these thought leaders and innovators and those were developing much broader statements :
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and then moreover, as you also heard, they remain in direct conversation with her direct provider system. if you get into the weeds of the models you heard about you will see how much time and energy these companies are putting into understanding that campath, forces acting on the provider community and support them and making necessary changes. implication of that is something worth thinking about as a group we talked a lot about insurance coverage and products but what we are is a lot needs to be done in actually redesigning the delivery system and that means a reallocation of roles for everybody in the system which we have to think more about. public policy is critical. the third broad point is a lime is becoming critical. any one of these copies i think i fell he said as big as they are doesn't influence all the dynamics of the provider community or the marketplace. they are having alignment of
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signal to the provider community and to the public is very important. we need a dialogue between policymakers and private employers about what that signal is and how it can best be reinforced by everybody's behavior and action. i also took away from observations about the employer, their concerns are the same as the concerns we in state houses and in congress. they are acting on the same concerns, the same calls, send called issues, the same variation images and trying to find the right toolkit to address those concerns. the are using some of the same approaches. very strong in today's discussion is a quality comes first for them. ultimately the biggest cost and the biggest concern is having healthy productive workforce that can make products and generate ideas and make things happen in the account of her country and of the world. that's the first problem to solve. cost, solutions will follow quality solutions.
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alice raised a great question about outcomes measurement and we all agreed where not we need to be so if we will drive the system toward higher-quality, we will have to measure that quality and design programs that improve that quality in an accountable way. these companies are all the forefront of making that happen. secondly, this is an intensive process. these companies are not writing a check and hoping for good things to happen and coming back a year later to see if good things happen. they are staying engaged in understanding and measuring to pick your lot about analytics from all of these companies. they invested in understanding their workforce, their provider community and the impact of the healthcare they are arranging on their workforce. this is not a superficial engagement. it's a deep analytic engagement at a lot to be learned from the analysis they've conducted. there's some differences, some things they do and can do that maybe don't apply as much to public policy. as you heard their workforce can be concentrated. it can be spread out. it can be rural.
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it can be urban. they've had to select and design programs that they can manage within the constraints of their particular business arrangement. an organization like medicare operates at a national level. there are precious to a uniform manner across the country that they don't have as much ability to tailor and flex. as we think about changes in health policy we will need to think more about how to allow for appropriate flexibility and necessary and socially desirable uniformity. they have very different case mix. several questions allude to the fact some of the younger, older, industrial, long-term tendered employees. it had to adapt to that. the public programs often don't have to think in those terms. i think the last issue is to think more together about the relationship to providers as distant from the relationship in the insurance product. macro and the implementation of macker as an opportunity for us
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to think in new ways about how to trigger value in the activities of the provider community. with that those are some of the broad things i've heard. now we will bring up some people really understand policy far better than i to talk about the applications of the lessons we've seen from the private sector and the activities of public policy development coming forward. i think joe will introduce the panel and i will invite them to come appear and take it from here. >> thank you. >> thank you, david. do we understand policy better cracks we probably have learned more by then the employers, but it's a big challenge. it was a great first panel and so now we will attempt to obfuscate and confuse, because of course we represent the washington outlook, least many of us do.
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so with that let me make a few comments notwithstanding there. david's comments were an excellent handoff for this panel. but he did mention medicaid. there's a tendency i think, i certainly haven't come to think first about medicare and then sort of medicaid is kind of tough because the state actually run medicaid, no matter what cms thinks. but i think there's a growing appreciation that the employers that we heard from this morning clearly recognize that if you don't pay attention to the client population, if you don't understand something about the delivery systems in the local area rather than in some generalized sense, that you
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probably will have trouble in fomenting cost-saving value producing changes in policy or the way you run your system. so i think there's a real possibility that as part of further reforms, that is, health reform is never going to stop. we're just going to call it by different names and it's going to continue on for ever, which i think is this panel because if that were not the case would all have to find other jobs. but i think part of the future health reform i think is greater appreciation for the role of states. i think that something that we may will see perhaps even in a repeal and replace bill sometime later this year. anyway, let me introduce the panel.
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i'm going to introduce people in order of speaking. so first we had len nichols, and let's see, i have defined that i do know -- len is a distinguished professor and director of the center for health policy research and ethics at the george mason university. and a washington person. he actually, i think you got your start in the clinton administration working on health reform, and you're still working on health reform. i know it's going great. [laughter] >> you win some, you lose some. >> exactly. next we have clay alspach it was principal at leavitt partners, and has spent a great deal of experience with prescription
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drug business, fda regulation and so on. he spent earlier times up on the hill, and so he knows where some of the bodies are buried. then karen fisher. karen is now at the association of american medical colleges, but before that, many years working on legislation for the senate finance committee and other roles. and then finally avik roy. avik has had an interesting career. i've known him for quite sometime now and he is moved around a lot, but he has started a new think tank. i don't want to think he's trying to be competitive with aei -- exactly, but it's a great
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effort called the foundation for research on equal opportunity. so it's not just narrowly focused on health issues, although avik, as many of you have seen on tv for many, many years, is a true health policy expert. and with that why don't we start with len, go down the row and that we will argue with each other until you stop us. >> thanks, joe. joe gave us five minutes suncor to try to make three points. >> you can use dan. >> no, no, no. i'm going to stick to five. that's there. so basically i have three points. to about what's going on now, and one kind of what i think maybe we need to think about going forward. first i want to begin by saying how happy i was to hear congressman burgess say the words bipartisan seven times. i counted. you can tweak that. this is important. but seriously, that is serious but it is a very serious point to say that there is a truly
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bipartisan support for the value agenda. every single paul ryan budget, go back and look at every single one of them, included all the medicare payment stuff that's in the aca. burr, hatch, upton, in my view, the most comprehensive congressional alternatives to the aca produced before the election, burr of courses chairman, not a chairman but a long time collaborator with tom coburn who always wrote the intellectually defensible way to think about this from the right on the hill. coburn retired sober took out the crucible. hatch is the chairman of finance. upton is the chairman of finance. very important. that bill includes all medicare payment stuff. and, of course, as congressman
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burr just laid out, macro pass with just about the largest bipartisan majority since i don't know, world war ii. it was pretty overwhelming. and so that is baked into the system and that's been very, very good, very, very good start. the i want to make is this public-private cooperation that has been waxing and waning and going on is a two-way street, and you think you can see a lot of good features that are coming out of that. the first and one of the things i like best about the way innovation center did its business pursuant to the aca was emphasizing multi-payer payment initiatives. the reason multi-payer payment initiatives matter is basically to try to get the incentives and reporting requirements and all the information flows aligned between payers so that clinicians can focus on what they went to medical school or nursing school four. i know of hospital systems and the commonwealth of virginia, i
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now have the privilege of living, that are participating in whole bunch of things and they are reporting between 240-500 different clinical quality metrics. as a simple country health economist i don't know what the right number of clinical quality metrics is biting 8240, i can assure you of that. we've got to do better job and the only way to do that is to get a multiplayer framework going. i applaud the participating plans and employers have done that sort of thing. there are lessons that i think you can learn from some of the different similar but differently structured activities. my favorite is patient medical because it is the core of making an aco work. it's the core of making healthcare system both more humane and more patient centered. that's the idea. it's been tested and lots of different ways. one of the largest public tests
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of the model was the comprehensive primary care initiative. the third-year evaluation by -- that just came out. i don't recommend you read in one day but i do recommend you take a look at it. it basically found, drumroll, no cost savings over three years. the only part of the country that saved serious money was oklahoma. you might ask yourself how the hell did that happen? and the edges because oklahoma actually has a really well functioning health insurance exchange, health information exchange which takes a data from the docs and gives them back actionable reports in real-time, combined all the payers and all the eh ours in his head and allows so-called big data to be operational for clinicians on the grant. they did, they saved money in your one that not in two and three. in general the program to do over, the costs associated with the rather in fact i would even say very demanding requirements
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of the government in all the things i wanted the primary care docs to do. so while they gave them $18 per member, per month, they spent spent it all delete all the stuff. contrast that with the patient centered medical home experiment and private sector. i know a fair bit about because i have been evaluating and it was designed by carefirst which is maryland, d.c. and northern virginia. it's unlike the government approach. they didn't dictate a whole bunch of things you had to do. they basically wanted you to do 24 summit access, same-day appointment. a attention to the data we give you an focus on care plans -- 24/7 access. agree by the nurse manager and the patient, signed the contract away. and go forth and prosper by focusing on those people. what i would say is they saved about 3% per year in years two and three. evaluation is ongoing but the
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larger point is this, kind of like what i heard our employers to say, they don't really want to get into the micromanaging basis of how to do it if you want to set the right financial incentives and information flows so that the docs can do it. what i observe is maybe an important lesson. it is instead of getting a bunch of experts for retreats in a room and saying this is what we think docs should be doing, maybe what we should be doing is focusing on which patients to focus on. because of is a very, very, very important thing. you're not going to save money on every patient. i don't care what you do. you would only save money on a particular subset of patients and there's a lot of ways to think about how to identify them and it's been a lot of advanced in so-called predictive modeling coming out of both claims-based and clinical-based data, in my opinion, the evidence the evidence and this is where obama comes back, the evidence is the data that do best of those that combine clinical data to prevent
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which patients to focus on. -- oklahoma. the third lesson that i would say or the third dimension of this public-private two-way street learning experience going on is a good secret of healthcare which no one has mentioned today which is kind of surprising. although sally alluded to for a moment and that is market power at the local level on the part of providers. as because walmart is, it can't really tell local hospitals what the hell to do. boeing is a little different place, and about three places you can do it. sort of kind of. but really into pr game. no big employer has enough market share to drive it. so let's segue to a better way, that we know oxman brine and others are going to push pretty hard come and heard burgess has always signed on. let me just point out, read that thing closely. it's all about turning medicare over to health plans, which
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sounds clean and nice and simple. but here's the thing. health plans don't have market power either over a whole bunch of hospitals. so if you got medicare out of the future service business and turn it over to health plans and say good luck am now i don't have to worry about it, i don't care, you will care pretty quickly because they are not able to drive the kind of bargain you really want, nor our employers. we need all the buyers to be focus on exactly how to move to the promised land. let's talk about the promised land as our third point. one really great feature of being tenured is your time to read stuff that you wouldn't have time to do if you were not tenured. [laughter] so i'm going to tell you three things you should read but again not in one day. the inspector general of hhs,
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you may think what the hell do they have to do with anything? they do analyses taiga, sort of, evaluation from own legal point of use of implementation. they are looking at the just released a report on the implementation of the quality payment program which is a big part of macra. it's about the position reporting stuff. you look in the report and you will see pretty clear recommendation for back office i.t., which is sort of, you know, euphemistic speak for figuring out how to get the data out of -- at such a way that we can actually do what we said we're trying to do in the legislation and in the regulation which you heard congressman burgess praise. here's aspect that's .1. point two, read that surgery evaluation written for the initiative and you will see even where we're spending 18 bucks
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for three years, you've got places in this country where the docs can't get out of their eh are what everybody agrees should be mentioned. and the third a little piece is a project i'm involved in, evidence now which is funded by h.r. q and the basic idea was to try to enable small practices around the country to be able to help manage patients with heart conditions much better for all the usual reasons. and i signed on as an evaluator for the virginia collaborative which is one of seven. and i was told by the pi of the project don't worry, every certified ehr can spit of the dating. you just need to work on the statistics. oh, my. so i've had to learn way more than it ever wanted to know about ehr, about getting data out and about the fundamental
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inability of eh ours to function the way were to promise of doctors to use them. let me bring you back to macra and nist. what we are doing in that regulation is where saying 90% of what you're going to be judged on in the first year comes from either your ehr or your report about your ehr. 10%% come from claims which medicare will happily compete for you and tell you what your total cost of care is. i submit to you those percentages should be reversed. we should figure out how to get the data out for the docs. the docs should not be required to produce these customer reports on their own because they cannot. they don't have time and we don't want them to have to learn the sql to do. we want to enable them to participate in an infrastructure where they can bring the clinical decision-making and sharing with patients all the data they need in real time, and it could be done because oklahoma proved it can be done.
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we need to think about how to build the i.t. backbone so that doctors can actually participate in the 21st century. let me tell you what's going to happen if we don't. these little practices which are still the core of our nation, especially in primary care, i'm not going to be able to compete. macra puts four to 9% within within three years of total medicare revenue at risk, at its total zero-sum. you will lose. they cannot win because they cannot make the ehrs generate the data to come out to do better. we have to do this for them. they can be done. it can be done cheaply but it's going to have to be an infrastructure kind of investment. i'll stop. >> thank you, len. that reminds us all in washington we have a different standard of measurement. so that was five minutes --
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[laughter] >> bill clinton time. [laughter] >> clay, take it away spin first, what to say thank you so much for the opportunity to be here today into speak. i know i just want to echo, i've learned a ton this morning from all the speakers, so thank you for all those contributions. what i'd like to talk about today first is the uncertainty here in washington has been what we've all been facing since the election. and the uncertainty, everybody who had a memo written before that commodore election they had to rip it up and recalculate, recalibrate on every single issue across the healthcare landscape. there were a lot of prognostications and a lot of predictions around that, and so what we do in washington really well is i'll make some predictions and prognostications even though you may get some stuff from before. i will try to do that here. i think what i will try to to do is walk through what i think
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they are sound and put it in data, or at least some of the things that may progress. one of the first things, what i would say related to the subject matter of today is that to move the value is going to continue. as we look at what's going to happen in the next year 2017, of course it's going to be very busy year across the healthcare sector here in washington. everybody's going to be implicated in the discussion. but one thing, i think you'll find is the move to value, it's a bipartisan id and it will pervade about what happens. what i'd like to do is walk you through three different settings, congress, the executive and the private sector about how some of the ideas from the first panel will present themselves during the policy debate that we are going to have. first with congress. dr. burgess, i worked a lot with him when i was on the committee,
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did a tremendous job of walking through what you can expect from his committee. that's what i did my work in energy and commerce committee. they will have a full plate. the predominant, what will hear and what we've already heard is about repeal and replace. so repeal and replace is going to be, take all the oxygen out of the room. it's going to be what everything is judged against. it's where all the activity from the policymakers standpoint, most of the activity is going to be centered. when you look at repeal and replace, and echo the bipartisan sentiment from dr. burgess was definitely welcome news. i think when you look at repeal and replace one of the questions that gets asked and should be asked is, what's involved in that? what are you going to see in that legislation? with repeal and replace and what republicans have been talking about since the passage of the affordable care act is a need to reduce costs for consumers.
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that has been one of their main argument that you've heard in every political ad to every policy debate, in the committee to the house floor is reducing costs for consumers. i will be a focal point of the policy that they want to put forward to try to accomplish that. the better way that dr. burgess talked about includes ideas as well as i would point you to doctor prices legislation on health reform. they both have one key component and that his health savings account. health savings accounts is something republicans of and talking about for a long time in policy circles. i think that is an idea that you're a lot about really well in the first panel that what you will look to do is find ways to foster, continue the expansion and to continue to make it easier for folks whether it's for veterans or for others, to continue with health savings accounts. that will be one important feature. a second part of it, and you
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will hear a lot about repeal and replace and about what's going to be in repeal and place. i think joe said it really well that a lot of focus has been on, and we talked about value, is on medicare but obviously medicaid has a big part of that as well. i think what you'll see an repeal and replace is to be a lot of focus on individual market and what can happen to make that work and what can happen to consumers but there will be a lot of talk about medicaid and what the future of medicaid will be and how that will move forward. medicare come it will be part of the debate. as part of repeal and replace. it's not likely to be a prominent feature. it may be a smaller part of it. i will walk through that in executive, what i talk about the executive branch, but medicare is not likely to be a big part of it. that's what you've heard from senator mcconnell, senator alexander, president-elect trump, others, that as much, it's a huge issue on the republican side.
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it won't be part of it. it will be part of the congressional debate. the fiscal year 2018 budget, so right now all the debate is about the fiscal year 2017 budget because of that is what's going to give the reconciliation instructions for the committees on the health side to begin that process of repeal and replace. a vote will approve the reconciliation instruction and the process of basically start. so phase two of the process will start. that is good to 2018, i bring that up because we are in fiscal year 2017 social to pass the budget after you already in the period. you are already spending the money but it's necessary to move the reconciliation for the republicans. for fiscal year 2018 i've been taught about the policy debate and they will conflate, is that there's going to be a real sense among the republicans in congress and from administration to try to find some fiscal
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order, that debates around spinning that should been part of fiscal year 2017 that were part of it. it's why the budget wasn't passed, i now going to move towards the physical year 2018 budget. in the budget as you look at it what we are seeing from the federal standpoint is that mandatory programs are crowding at discretionary programs. when you look at the caps that are a essential part of any budget from the federal standpoint, the discretionary caps as to what you can spend what it that defense department, defense or how much for health care or how much there's going to be for how much more money through before nih peer, that is centered in this debate. the issue that has been here and will continue to be a problem according to the republicans and less it solved and speaker ryan talk about this and account all last night is that the mandatory program, medicare, medicaid are crowding out the rest of the budget. they need to be broad and the
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need to be some kind of order brought to that in order for the federal budget to actually work. that would be the policy debate that happens, and i think on the medicaid side that will be part of repeal and replace bick u seal that you see substantive changes you need to take into account. on the medicare side, his budgets are very important for policy debates and for setting this caps as a talked about. they are not going to change substantive law. so you are not going to see, if a prima support also included in that budget, it's not going to be part of law so it doesn't anything that would directly affect stakeholders. that is something to caution and to qualify but that will be what the congressional debate will center and something to keep into account. the move to value, the need to reduce cost to improve quality, that will be something that is talked about as part of his policy discussions. so those topics of the first
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phase will be part of that as well. now, where will the debate related to value continue or the policy questions continue? in the executive branch of that is definitely something that is front and center on the plate that they need to contemplate and think about. with respect to that, while some, republicans would want to move forward with medicare reform him as i said it's not likely to happen just because there's enough on their plate and is a political sense they can't take that on as well. that said, on the executive branch and the power that is there may present opportunities for them to test certain ideas and continued to test certain ideas that are already started whether the bundled payment, the aco, others. that's with the question will come for doctor bryce and for others that are situated there. as to what they want to do and how they want to move forward with cnmi, as an example.
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with that i think, the relationship of cnmi and i will move forward, the past year you had seen basically the name recognition of cnmi and the understanding has changed dramatically. i think from a correctional standpoint and republican standpoint. while doing a lot of work and moving forward a great deal, there was a lot of focus except for folks like dr. burgess and others are really in tune to those issues. that is a place where the name recognition has gone higher and it is great concern among folks as to what its future is. it's my thought and i will walk through why is that cmmi does play a large role and will play a large role in a new administration and it's for several factors. the first is macra. karen and i had an opportunity to work on macra when we were on the hill and deceit get it enacted. for macra it's macra is a
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bipartisan piece of legislation. that is a key factor here. both sides of the aisle want to see it succeed. both parties want to be right. they will take steps with working together on letter to semester working with cms and others to ensure it works. so they want to make sure cms is going to continue with that as dr. burgess articulate it. he's going to have hearings at his subcommittee and hearings other places to make sure macra continues. but for macra to continue and for the advance, one of the key components of the quality payment program, it's the advanced abms. you need the programs, the models from cmmi. so you need those their to qualify for the bonus payments. it changes that will be seen if his ink had a change to the programs or there are discontinuations, that's going to cause a lot of problems not only with, it will cause a lot of problems with stakeholders
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across the country who view that as a very attractive place for them to be. they're not going to get the negative adjustment. they can continue the investment and the move to value, and they can move to a place where quality is important and they can move to a place how they want to practice. so that is one place that executive branch as dr. price and others take their positions, they will have to consider. the second piece to this whole, this is something congress has to do with as well as the executive branch is that cbo, the congressional budget office, believes cmmi actually was saved the fiscal federal government a great deal of money. i point you to the testimony in front of the senate, house budget committee back in september where they testified in the test might be outlined really lay out why they think it's going to happen. it's around the process. so it's around the process cmmi utilizes to the forwarded these
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demonstrations, program. they believe that process is a really good process. it's not necessarily what has been picked up thus far. it's around the process to move forward these quickly and to get them out to task them to see if it actually work or not. under cbo is estimation, the next 10 years they will save $34 billion for the under cmmi. in the out years probably a great deal more. that's something the executive branch and congress will have to consider as well. the final piece to this, an important piece, is because of the duckling to be a substantial medicare reform likely in this congress, the question is where do those ideas come forward, how can republicans move a look at conservative ideas in medicare, and how can they test their own ideas? you have the apparatus already set up. so that's where you could see different, whether it's a prima support model or other models being put forward under the
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executive branch. you can see that in medicare. medicaid, you could do it under chip. there's other ways for them to test this out. when it's your power, your ability, your car to drive, that makes it less likely you want to get rid of it. so that's something to consider as well. and then finally i will move quickly to the private sector. i think with republicans and democrats as well, they want to hear about what's happening in the private sector. they want to hear about the success stories we heard about on the first panel. and that private sector leadership and the data that they can share our incredibly persuasive, incredibly important for them to be aware of as the moving forward. one opportunity that i think is there is around, with cmmi and some of the executive authority, they have the ability because they are operating these public
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programs and because -- to waive certain requirements. they can wave certain whether it's a kickback statute or starker of the pieces that make mickey's malt or demonstrations harder to implement. as you look at these private sector opportunities and i think the bipartisan relief, how can we foster it, will be looking for that. that's one question i would pose and it was asked earlier by the audience is, what can be done to basically foster an environment to move these forward in the private sector, and what can be done to reduce those burdens. this is something that congress already indicated they're interested in. i know karen's former senate committee finance, there is a white paper released by chairman hatch. there was a hearing that was held by their asking these very questions. i think that's an opportunity for folks outside of these public programs to move forward
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to continue to show the leadership, to continue to share that innovation so that we can move forward in a good way. >> thanks. dr. burgess raised a couple of questions, which probably a good thing he didn't answer them. and his questions were, as policy drive innovation or does innovation try policy? or does innovation occur in spite of policy or independent policy? i think that's that's probably the better way to think about it. you know, there are an awful lot of people who seem to think all great ideas stem from the expert mind in washington who are insulated from much of the real world. i think that's a real problem when it comes to setting policy. in the end federal policy will drive an awful lot of what goes
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on. the first panel, at least one of the speakers, several of the speakers i think, pointed out that there's a tendency for washington policy to want things to be uniform across at least the medicare program. medicaid is even pressured to be uniform in the medicaid program, and that's a real problem. i think one of the lessons that we can certainly take from the private sector is that uniformity doesn't generally work, and less accidentally you can find to situations that are fairly similar. and with that, karen, take it away. >> thanks, len, i think for the invitation today. i'm going to do survey litany of items because len and clay did such a good job of setting it up and want to make sure there is time for avik. what we do want uniform is we want high quality care uniformly. how that's done and how that's done in local areas can differ,
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but i think with the opportunity with telehealth and with the opportunity to spread information quickly, there's an opportunity to mature that we are used to high-quality care only happened in certain parts of the country, an opportunity now to make through clinical guidelines are other mechanisms that we can get that across the country. as i do think we would probably all agree on that. i do want to pick up a little bit on macra and the idea to bring in the private sector. as clay mention this was a physician payment bill the past several years ago and for several years prior to that there were a number of hearings done by both on house and on the senate side that brought in the private sector, employers, physicians, providers, health plans and said what are you doing? how are you working with your physicians to ensure high quality care in a way that also is fiscally prudent? there were lots of letters and discussion that went on. sometimes all legislation can
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take a while to happen, that could be a good thing because it allows for the type of discussion to occur. i think that's in part why that bill was so bipartisan and had a lot of support by the physician community and the provider community and others was because they were so much a part of it. i think that's important. let me point to another example about this happening more recently, and that's an effort on the senate side in the senate finance committee that's been working on a chronic care bill. just like for the medicare program, the chronically ill of the most expensive segment of that population, and trying to get a handle on making sure those individuals have high quality care, in a way that can also look at the cost of that is very important. senator hatch, senator wyden and warner and isaacson can together, the finance committee and had again a lot of discussion with outside groups about what they were doing with
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the chronically ill and put together a white paper that introduce legislation at the end of last year. bipartisan legislation that was introduced to look at ways to improve the care that the chronically ill received. i think that's going to be an effort is going to continue, because while there can be disagreements on one issue, oftentimes as clay and i and others know, there's discussions going on where people agree on other issues that i think chronic care is one of those areas that we should watch out for. the panel before talked about quality and the need for quality measure. i was pleased that in the physician macra legislation there was money put into, $15 billion a year for five years, for measure development. quality measure development is not a big moneymaker for private industry because the measures have to be public and it can't
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be proprietary. so identifying and as was mentioned before, getting good outcomes measured and getting those measures so we don't need hundreds of them i can get to be a subset, really identifies with high-quality care, it's important. i would argue that's almost a governmental role of saying look, this quality measure to undoing in this country, and government has a responsibility to help fund those measures rather than put them on physician groups are provided group for health plans etc. len mentioned quality alignment. i think there's a role for the government to work for the medicare, medicaid programs along with the private sector and some of those efforts are ongoing right now with bollinger efforts that are occurring between the medicare agencies and some of the other health plans. i think everyone would agree and certainly when clay and i were on the hill we took lots of meetings when it was exactly the case, that providers came in and
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said how am i expected it is where i have different payers, and yet i'm being expected to all of these different quality measures? in the midst of everything else that's happening right now, len mentioned about the health i.t. area. intel -- in 2008 or eight or nine the government did put funding into encouraging, incentivizing providers to implement more health information technology. the good news is, lots of people took them up on that, and hospitals took some of the money and put in a lot of health information technology. they put a lot more money of their own in. and physicians also put them in. you will go into a lot of physician offices, hospitals and you'll see computers. the issue is now translating that technology into true information, and how do we utilize that as they gather information to improve care? i think that this administration as we look forward has to continue to build upon that and
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see how we can utilize the private public sector role to take health information and make it not just from technology into information. and then to build upon that, it is the data piece and getting feedback data. and macra i think part of the reason why people use of favorably is because it tried to address many of these issue. macra is information and to talk about from a medical perspective making sure medicare agencies give feedback data to physicians so the physician can see what's going on. not only for themselves what they are doing but when their patient gets into a hospital, what about postacute care? what's going on with the patient? its by far not perfect and i would say one of the issues is that the government and the medicare agencies don't have probably the systems they really need in place to efficiently turnaround feedback. there's a recognition that needs to be done, and begin in the midst of everything else that is being done, these are areas that
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probably need to be looked at. when we look at value, the other thing we have been seeing as these alternative payment models and value-based purchasing and readmission testing readmission programs have been taking place is we are learning more. what we are starting to see is a socioeconomic status makes a difference. with providers. while providers have a certain role and can do certain things, sometimes a socioeconomic conditions of their patients, the environments and whether patients live, whether they have a family caregiver around them, whether they have transportation, whether they have good nutritious get around them affects how much health care they need. as we start to look at policies we need to look at issues we have not looked at before. things like socioeconomic status, my risk adjustment, et cetera. and then finally i think on my
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list is that women talk about the private sector we probably do need to look at the anti-kickback rules that were set up in a different era, and a fee-for-service area where we're trying to say oh, if anyone talks to anyone else or tries to influence them to get a kickback for the care. we're in a different world now where we're trying to encourage collaboration, encouraging coordination and that's an important law that needs to get done. i want just finished up with saying one thing. i was asked to be here for the most part because of my background working with the senate finance committee. another chief public policy officer for the association of american medical colleges and i will take 30 seconds with the party was to say, when here about the private sector to look at reference pricing and look, given more transparency about the price to providers, as the gazette again we cannot look at those issues and assignment. we have a look across the board in terms of all of healthcare
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that occurs -- in a silo. if you look at the major academic centers in this country there's a subset of the population but they do all of the physician education and that costs money. they are the places whether standby capacity and whether the next people crisis occurring they have to have -- ebola -- that cost money. historically medicare has paid a share of those cost, not all of them. to be honest the private sector the goshen rates probably has picked up some of that. to the extent will get more transparency about how much it costs, will have to have an honest discussion about how those other costs that benefit everyone are going to be taken care of any type of new system. i just encourage us as we think from a policy standpoint about that that we have to look across the board on all those issues. >> okay. that should be easy to handle. [laughter] some irony, i don't want to
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admit how old i am, but i do remember in the early stages of my career back in the dark ages were talked about care record nation come and that was of this in error the antikickback rules were put in, which were clearly meant, and once again, washington policymakers did not understand that things are connected to her that i think one of our biggest problems, that we the connections and, of course, many of these things are hard to see until you do something. and then realize you may have a problem and then the issue is are we able to then admit that it doesn't work anymore? i think i will be a real challenge for the foreseeable future. anyway, avik, please take it away. >> thanks, joe. great to be with all of you. maybe what i will try to do is draw from the earlier panel we had with a large employer, because i think part of our task
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was to say what lessons can the public policy committee learn from a large employers are doing. and then step back and talk more about the broader context of my views at least, my two bits on what conservatives and republicans in congress should do on health reform more broadly. i'm going to talk about three things i drew from the large employer discussion. the first is a discussion of account-based reimbursement, so health savings accounts, advertisements, et cetera. ellie did a great job of describing how they are seeing quite a bit of uptake satisfaction improvement in utilization, quality, et cetera. i think one of the most promising aspects of the new reform environment we're in is that help we can broaden the utilization of its lessons. broadly speaking we have been living in this era for about 50 years where the central dogma of healthcare economics was handed
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to us on stone tablets by ken arrow at stanford who said the laws of economics were magically suspended when he talked about healthcare. i think what large employers are learning on our behalf is the laws of economics are not magically suspended when we talk about healthcare. the laws of economics applies to every good answers that is transmitted through economy and if you give patients more control over the health care dollars to be spent on their behalf, voilĂ , given more patience and care system because should be surprising because i saw the rest of the economy works. sometimes we struggle to appreciate these basic lessons in healthcare. that's point number one. more agencies for patients, for consumers is better. the second point i think to draw from the discussion was the value of longer-term relationships between payers and patients. this was a missed opportunity with the aca weathers anaerobic. every year which means if you're the insurance company and
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rolling a patient for a year, a lot of the long-term preventive health outcome type work that you might want to do, you're not sure you will capture the value of the work down the road. we heard from dr. burgess about the high price of hepatitis c drugs and why we should pay whatever they want to charge because they cure hepatitis addenda record that an insurance company doesn't necessarily capture the value because 20 years down the road there on a different entrance point or medicare. one thing we can learn from switzerland is the value longer-term insurance contract. if you have a five-year insurance contract rather than a one-year entrance contract, for example, then an insurer has a lot more ability to say i invest in prevention pharmaceutical with cardiovascular comedy set of issues, i'm going to use the savings down the road and i can translate to lower premiums. so the more we can move to longer-term relationships between payers and patients and
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again at insurance contracts to reflect that i think that would be a significant value dry with a lot of us are not talking about in the policy world. the third thing i'm going to mention is price. a number of colleagues 20 years ago wrote a great piece called it's the pricing, stupid. his point was we all talk about utilization and say we just have reform delivered and tweak of this and that's what people don't go to the hospital 20 times for this instead of 19. saw great and we should do that very hard blocking and tackling and plumbing work. one thing we should understand is when all completed at the high cost of u.s. healthcare but utilization is not the driver of the high cost of u.s. healthcare. to take one common metric of healthcare utilization which an average length of stay in hospital, we are one to 90 days below the oecd average for an average length of stay in hospital. we are much better that are typical european or canadian or
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australian peers in getting people out of the hospital. we are already doing a lot of good stuff. the problem is the average stay costs five times as much as a average stay in hospital somewhere else. that's not because we're doing five times as much stuff is because the mri cost six times as much because because the drugs cost 50% as much. it's the prices that are driving high cost in the united states much more than utilization. we should do a weekend to make sure we're not doing appropriate care of course but if we don't tackle prices we are not going to lower cost. i think the experiment on reference pricing with orthopedics and in other areas is i think incredibly important. it showed you had a lot of providers that we have deterred $40,000 for a dollars for a new replacement because that's the underlying cost. you can't -- we will go broke in, closed. with calpers said sorkin will not pay you for 1000 we will pay
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you ask, and if you don't, the patient will go somewhere else. magically all the provider said that's a great price, that's awesome. there's an enormous amount of fat in the system based on prices that people are charging. this distortion was created by the employer tax in world war ii and the medicare system thinking about 1965. the more we can move away from that and give payers more flexibility and latitude in pricing, particularly reference pricing, i think that's extremely important. i also want to thank joe because we were classmates in high school michigan is extraordinary 30 years ago and so you give me an opportunity to run into her after all this time, which i appreciate. she will probably kill me now for dating her. [laughter] so now let's draw back and say what is the end by the? i want to something i think alice rivlin talked about and that is importance of
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bipartisanship and the health reform discussion. i am personally concerned a lot of republicans, while they criticize the ac for being passed on a partyline vote either resigned or eager to doing the same thing in reverse. doing everything through reconciliation would only takes 50, 51 senators as opposed to try to come up with a durable health reform at a 60, the of at least 60 senators. i think they can be done. to get my think tank a blog, the health reform plan republished at the foundation for research on equal opportunity which you can get on our website, it was built from the ground up to be a kind of plan that can achieve the objective of both the democrats and republicans. it's designed to cover more people than the aca, improve healthcare outcomes for the poor by reforming medicaid but also reduce spending, taxation, regulations and cost by utilizing some of the techniques that we've talked about. it doesn't have to be exactly like that at a general set of
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principles, let's try to achieve the democratic objectives of coverage expansion and marry those two republican objectives of less government and more cost control. that can be done pick the ac didn't get that done to the degree certainly a lot of us wanted it to get done. i want to encourage republicans to do that. that's how you get the 60 votes for any replacement of the aca. if we don't do it then the result of this new environment will not be satisfactory to anyone. what you're only going to be able to do is take the past credits or the dollars the aca was spin and maybe spend in a slightly different way. once you can change the regulation and other key elements that are not subject to the senate reconciliation process, you are not going to get to a more market-oriented consumer patient driven healthcare system. thank you, avik. that's a great way to end the formal remarks because it leaves one with a sense of despair. [laughter]
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you know, one of the big issues of course is how do you make that straddle from a system that anyways hasn't worked, to a system that might work? i think that's going to be one of the big challenges, not just for republicans but for democrats. even more importantly for the health sector and for patients and consumers. i think there's a lot of talk, especially in the press that this is so much as a political issue. that's wrong. it is true that a lot of middle-class people have no idea how the aca may or may not affected them. they have no clue whatsoever about that. they also don't know what they pay in premiums generally either. that doesn't mean they are not being affected. as we go along i think we're going to see both because of the pressure for a kind of price transparent to the probably
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isn't useful, but also the reality that employers can which is where most people get their health insurance, employers will not be able to conceal the fact that they are taking the money out other out of raise wages and putting them in healthcare sector. i think we'll see some problem there no matter what washington does over the next year or two. there's so many issues here that i could personally take issue with, but why don't we see if other people have some complaints before i start ranting and raving? >> i talked about reference pricing and candidate as well. make that let me make one point about this whole issue. i appreciate i went to medical school. i appreciate medical schools have costs that are different from a community hospital. it doesn't seem to me that the right way to subsidize that is to make everybody pay more for the health insurance. maybe the right way to pay for that is to direct subsidies to
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go to academic medical centers. clean that up, instead of advocating for a status quo that isn't serving anyone very well spirit that the conversation worth having. you need with these types of systems to the stability over time so that the direct subsidy would have to be stable over time but i think that's a discussion with having. i don't want to turn that into that type of discussion. ..
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what i worry about is that sometimes the easy decision for the federal government is to shift the cost, reduce the federal government spending curve, but the cost moves over to the state or move over to beneficiaries. if we can actually get providers to work together and look at ideas to bend the healthcare cost curve, everyone wins under that. federal federal government wins and beneficiaries when. >> to bend the cost curve means to spend less money. i have that wrong so if you spend less money, that means hospitals will get paid less, doctors will get paid less. >> not necessarily. if you cut out the middleman. >> wait a minute, this isn't
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isn't economics, this is accounting. >> not at all because what our hospitals and physicians spending a lot of money on. it's not just revenue. it's cost. income is revenue minus costs minus tax. if you are billing for a lot, but you're also spending a lot on compliance and regulatory cost, then your actual income is lower so yes you can spend less money, but if you actually streamline the system so the cost of delivering care in terms of regulatory compliance, middleman, billing, if you can reduce those costs you can have more savings in the end and a system that stakeholders appreciate. >> certainly, if you could reduce administrative costs to that extent, i would agree with you. the issue goes back to will we ever really divorce ourselves from future service payment.
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basically all payment systems have the space because you have to start somewhere. i'm a big fan of capitation, but below capitation the doctor has to be paid, and what's the basis for that. the big hmos don't like to talk about how they pay their individual practitioners, but it's highly likely there is a volume basis, at least in part. there is some kind of a performance measure that isn't just volume-based. it's a very murky system. there's there's also probably a salary component mixed in, but a base of payment for practitioners. it's not at all clear how this miracle will occur. >> joe, joe, there are plenty of ways you could get to the miracle. let's be clear with you, i agree
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if we didn't have it we have to invent it. we have to account for what's going on, but you can do that without having 1500 different different pairs at different ways of paying for roughly the same code. what got to do, i'm back to alignment. that is my magical thing for the day. what if we agreed that all the payers would have the same set of quality metrics by which they are going to judge the individual providers. yes you can pay different levels and yes you might have different forms of incentives or rewards, but as as long as the metrics are the same, and as long as a provider has clear incentives that are applicable across all payers, then you can get to nontrivial efficiencies. i will also remind everyone of the claims adjustment algorithm. a lot of the billing stuff that doc spend money on, what is it 20 cents for the hospital to get
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paid and $.35 on the dollar, that's all, that's all about having all these different pairs with different rules about how to get a claim accepted. what if we had standardized way to do that, and you know damn well we do, we just don't have the courage to them enforce those standards. it is achievable we just have to have a little more targeted courage. >> this is where healthcare it can play a role. you don't you don't have to have one-size-fits-all if technologist can play a role in being the interface decision on support tools for providers and payers and the like. that is restricted by anti-kickback laws, hip out, etc out, et cetera. that's a whole area of work where we need to spend more time so athena health and whoever else we want to put in that bucket can do the work to be
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able to interface and create a system where everyone can work together, and it would take those costs out of the system. >> let's be clear, we don't want to turn this over to ethic concern her and say good luck. the fundamental problem is that no one's focused on getting the permission, all the data they need to make the decisions they need to make. >> they are legally barred by doing that because there certain types of information. >> they are barred by antikickback laws from doing that if they make money from doing it. >> i'm totally in favor of fixing start but that isn't the problem for the biggest problem is somehow, the vendors have to be owners of the data. that's wrong. docs and patients should own the data. we have to fix that and then we can fix everything else. >> autonomous call it
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externality. when you talk about the fee for paper service, i think think when you look at macro, that's the representation i'm trying to move away from when you look at the quality payment program. >> man, that's really great. [laughter] >> now it's just meaning that that's where everybody is situated now and were trying to move them to alternative payment models, but that's where the ideas from this morning's panel are trying to be represented in private programs. >> okay we want to get into an alternative pay model discussion discussion -- i think there's a fundamental issue that several people alluded to which is the short-term view that health
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financing and health policy takes on everything. it's somewhat ironic, the medicare program ought to take a long time term view because with the baby boomers, they're stuck with them for 20 years or more and yet most of the policy is oriented to one year, and if there is broad thinking that tenure score ,-comma what really matters is year-by-year. that's a problem. it wasn't emphasized in the employer panel, but you you would think that the large employers would have a longer-term viewpoint, but i think they're trapped in the mechanics of short, one-year contracts with health insurers. clearly the big employers recognize that their workforce,
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at least for highly skilled part of their workforce, they want to hold onto. that's also a long-term relationship relationship and yet all the financial relationships have been really more focused on the short-term and the long-term because it's so hard to capture what was the result of whatever you did upfront as a health investment, how does that really affect health and cost even first the past the first year. it's hard to know. i just want to make that observation is something we all need to work on. >> that's why made the point about long term insurance contract. >> i think a lot of people have been thinking about that for a long time and the reason we don't have them is because health insurers, let's be clear about that but let's think about what the deal is. insurers want the freedom to observe, you turned out to be sicker than i thought, and
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patients want the freedom to observe, i don't like the way they're treating me. we do have attention between longer-term commitments and choice and protection from risk. i would also say, let's remember the providers are just learning how too do risk. we been paying them for quite some time because price, we been overpaying for quite some time. i'm not sure i'm going to be pessimistic about the fact that the providers in the boeing world don't want to go to a multi-year risk risk contract. i'm happy they're doing one-year risk and they're actually hitting your target if i heard you correctly. i think we should acknowledge the good stuff that's going on. >> absolutely. the only question is, how many decades into the future, and i think part of that has to do with government policy and medicare is a big pair. medicare doesn't push against its own comfort levels which are
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far closer to the body that i think any employers are willing to take chances because there's money at stake that. >> so let's talk about it during risk and why medicare's focus is so short. you know as well as i do it's because of the people we elected and the fact that they have to worry, kind of a lot, about getting elected kind of quickly. if your to your congressman, you can be talking about a 20 year medicare, your to talk about what can you do today. that's why you go back to this chronic care model, that's incredibly long-term thinking. it's actually informed by evidence. you've got to encourage the congressmen to think longer. how do you do that. you tell me. a long-term contract? >> i'm sure there's some kind of pharmaceutical -- >> long-term contracts are for
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everybody, but i think having the option in a way that the federal policy inhibits against them is important. >> some of these models, it's pushing the rest of the provider or the plan, it's moving the idea, it's trying to do that. >> right, and i think having organized health plans really helps this efforts. it may be more optimistic about this movement in the end because those are business organizations that have some sides to them. >> speaking of learning while you're doing, think about how medicare advantage today, in my view is much stronger in my view than it was 20 years ago, precisely because so many americans have had experience with managed-care plans and it turns out it's actually good thing in many ways. >> you know what, that's going
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to be true across the board in these private-sector initiatives on initiatives on teaching consumers how to be smarter consumers. my mother was not a smart consumer. i love her very much, she died died in 2004, she did exactly whatever her primary care doctor told her to do. >> if that's what you think, that's what will do, but my child does not think that way. fundamentally it's about learning behavior that can help us be better consumers. >> so with that, other questions from the audience raise your hand. >> there's a lady here. >> thank you. i make with the national quality forum. you both mention the importance of alignment that you understand how wed people are to their quality measures, how your shoes are good but my shoes are better mentality. how do we overcome this challenge.
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what are your ideas and thoughts >> i would encourage the following historical metaphor. constantine, when he took over the empire had a problem, and the problem was, christianity christianity which he decided to make the religion of the empire was split between those who felt jesus was a man and those who thought jesus was a god. so he can convened the bishops and he said to them, i really care if jesus it is god or man but y'all ain't leaving until you decide. so what happens, turned out he was both, solve the problem. my point is, you have to have a deadline, you have to have a sword and you have to have very clear instruction. in my opinion, for what it's worth you could get the relevant players in a room, cms can't
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dictate, but the cms sword might be that you all have six months. at a really care, but if you don't agree with you do it our way. i guarantee you they will pay attention to get not fixed, but you you have to have the sword and the deadline. >> one thing that has bothered me about this concern of hundreds of measures, everybody's right about that, that's too many measures. if you expect everybody to report on those. but, one of the issues is that some measures are actually appropriate so it's a much more complicated world, as you well know that i think is often portrayed. it's really difficult. we sent you out there without the sword, and were very grateful for what you do, but you can't really make him do it
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on time and as you have the sword. you don't want cms dictating before the private sector has a chance to work it out. if you can do that, a lot of suggestions in history would suggest that the peaceful way to do it. >> great, good morning. my name is jean with healthcare dynamics in a national and this has been an amazing panel. thank you so much. we have the opportunity of working across the country trying to do the transformation of clinical practice this is and were clearly seeing the challenges with the small rural practices. clearly the data, you're exactly right, they just can't get the data. my question, appreciate your your comment around the social determinants because many of these are trapped whether her in
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rule areas or urban areas, the trapped by the challenges by morbid diseases and challenges of, social healthcare which is far more than health. my question to you is what are some solutions that you as policymakers around and across the system, particularly particularly with the small role docs, that they are facing. how do we get through this debacle around interoperability and two ,-comma what are your thoughts around risk-adjusted payments because clearly there's the option of cherry picking, i don't like to say that, but ultimately how do we manage those. thr and risk adjustment, particularly with the focus on the small role doctors.
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when i left my hotel this morning to come over to aai, there is a copy of the wall street journal in front of my hotel room door because the hotel had in their database that i liked having the wall street journal when i got checked into that hotel. there needed to be no meaningful use regulations require my hotel to deliver the wall street journal to my dart door in my hotel room. they did it because they had an economic incentive to provide high-quality service to me so that i would keep going to that hotel. the irony of all the stuff we talk about with electronic health records is out again, in the rest of the economy is out of the rest of the economy do it. the rest of the economy, there needs to be no regulations around mandating people to use digital data because it's in the
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economic incentive of the supplier and servicers and goods to be what the customer wants. it's only in healthcare that we have to do the spread the more we can reform broadly so the patient is in control of the healthcare dollar, i think a lot of the stuff around getting people to use the staff will fall under the government and get out of the way and it doesn't actively sabotage. and will get a lot better. look at that thing in the real world where it's working. go back to tulsa oklahoma where this engineer undergrad who works at the university figured out, using banking colleagues how to extract the data from the individual rule practice, the small practices in such a way that the doctor doesn't have to
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do anything. they finish the exam, close the record, the data flows, you know what i'm talking about. straight in and it takes all the patients and gives him back a profile. you got three diabetics and three with heart conditions and three of them coming in tomorrow who haven't been here in two years. that all comes back to them in a dashboard in the morning. you walk in and there it is. how do they do that. they do it through software that is eminently achievable. it can be written by my graduate students. but, they have essentially penetrated the wall that prevents this from happening in most of the country. why because they were given too much power by the federal rules. i would rule it's because some people in congress wouldn't let them impose rules that might've been more productive, but here here we are so let's fix it. it's fixable and you can find examples where it's working. you just have to break those
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firewall. >> in the new act that was enacted in december, there's there's a significant amount of work that will be pushed to the office of national coordinator to work on the interoperability because i believe there's a lot of concern not only among folks around the country but that have come to washington and they are trying to push forward. the second pieces i agree, the consumer is really the key to this and the more the consumer, the more their demanding this type of information, as folks care for their parents or their kids and are dealing with these record issue, i think they are gonna be what pushes us forward. they really want this to work as well. they want to be able to share it but they want to be able to do it in a way that makes sense and as we all know it's a very complicated topic with a lot of
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privacy concerns around it. it's somewhat different from what we've seen in other parts. >> but there are solutions. >> i think we continue the same as on the quality side, we need to give this more finance and as people live longer and were managing chronic illness more carefully, risk adjustment is just going to get increasingly important. >> and increasingly difficult to do. >> anybody else. >> okay, go ahead. >> thank you for your presentation. my name is d young and i think common sense is a price and a cost. it depends on the consumer to determine how much you can save or if you cannot forget. you can see it may be more
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useful i just wonder if the information from all those providers can give the consumer information, the treatment, everything that's supposed to be in regulation. that is not true. you have the right to compress. so do we have mechanisms for better procedures that have a record of result and resolution that if we can have all that information available we can share which officials are doing
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right and which are doing wrong. [inaudible] we will know if we are in trouble in terms of health or financial situation. >> right, that's a really good question. if it's down to getting consumers to better understand both their condition and what their options are for treatment and providers, with the aftermath of the treatment might be, and cost, and one of the problems with the transparency push in washington is they want to talk about list prices all the time when in fact what the average person wants to know is
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what is it's going to cost me out of pocket. it is true have for a lot of purposes you really do often want to know what is the actual transaction price. for the average patient they turned to focus on dollars out of pocket. even though they are ultimately paying the rest of it, we need to address those issues. >> there are tools to do everything you asked for which is quite reasonable. i would say the difficulty we have, the difference difference between where we want to be where we are is that we put a pretty big burden on the patient to ask all the relevant parties all the relevant questions about themselves and in some cases it's the laws and regulations that prevent the stuff from flowing as easily as it should. i would just observe that the burden on the person to ask the question is part and parcel of
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our philosophical attraction to the notion of individualism and choice in patient centeredness. it's kind of hard to push it in less the patients ask for it. >> i will say, a lot of the dhr can generate the data on a patient in that physicians office, but not necessarily every physician you've seen in the past three years and not every er you may have been into from some emergency. getting patient control and access to the totality of your records, in my view that's why we need a system that enables you to access that every morning or however often you want to go to a dock. it's feasible and they are in technical terms but not in legal and administrative terms. >> one more question for observation.
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>> thank you all for the panel discussion. several of us have alluded to market forces during the day and we haven't come back to it yet. this discussion opens up this discussion as well whether you all believe individual consumers acting individually will capture the dominant forces in consolidated health plans which are in fact about price setting or prices which are driving higher prices in a lot of situations. our employer friends also find themselves victims in the market where they don't have the power to counteract or negotiate down. what do you foresee as the policy options in the next few years to address the effective consolidation on price that would bring all u.s. pricing into more alignment with international norms? >> it's a great question. there's a whole question that addresses this problem with consolidation because it's so important. a lot of federal policies like the aca and others are
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facilitating and encouraging facilitation because of all the compliance and regulation you can only get to that point with the economy of scale. that's a huge problem. i think there's a couple things you can do to improve provider competition. the first is we can do something at the state level where there are certificate of need laws and it prohibits providers from entering the system. i think it's important to try to reform that. the same goes for physician owned hospitals. i understand not wanting those but they are an important element of competition for providers. i have to think you need to give more money to litigate. basically if united and continental airlines want to merge, it's a big national merger but if it's the local hospitals in cleveland, that's
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too small for the ftc and the doj to get involved but i think we need to do more to draw resources. i think the last thing which is a more out-of-the-box idea is that you could conceive of a system in which there was an automatic trigger. instead of relying on doj litigation, you can have a situation where if provider concentration in a certain locality exceeded the threshold of concentration were also and you had a monopoly level, you trigger a regulation which sounds like a heavy hand of government but what you're
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basically doing is if you want to stay independent and compete, do that. if you think through merging you can add economy of scale to lower cost, do that, but if you're only merging to get market power and jack up prices on patients and taxpayers, were not going to let you do that. >> okay, well i think this is where the employers play a really critical role. they represent the workforce, not not just in healthcare but in total compensation. i think if you are asked the average employee,, if we want to give you $10 more would like to spend it on healthcare, the answer would be no, almost certainly.
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the ability to resist i think is very important. i think the problem were talking about his good economic sense. we can't complain about good economic times, but it's it's very easy to say oh yes, we'll pay it because we don't feel enough pressure to push back. we may be headed in that direction not from the position of a negative a common enemy but the lack of balance or the missed balance between healthcare and everything else may have gotten to the point where we may be at a proverbial tipping point, asking and acknowledging that employers have a job to do. were counting on you because in washington, we would really like to have someone else do the work for us. >> can i ask one more? the employer front. this is something that really struck me.
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find a way to share what you know about price differential across the country because the deal is medicare dictates prices. they don't pay variable prices, but y'all pay those things. that's not part of the database that triggers doj. economists discover it by chance every couple years, but you know every single day. figure out a way to share that. >> there's got to be away. just show up. >> okay, good. we have expired our time. please join me me in thanking not only this panel but the entire group of people. [applause]
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[inaudible conversation] >> a live look inside trump tower in new york city. the president elect is here today holding meetings ahead of the unknown operation next week. some of the people meeting with him today, the ceo of lockheed martin. he went in the elevators within the past half hour. also the labor leader who actually just left. mr. trump is also involved in the action going on in capitol hill dealing with the federal health care law. he tweeted this morning the unaffordable care act will soon be history. the house is working on a resolution to begin the process of repealing the affordable care act and currently debating that measure in the house right now. you can catch that on c-span.
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on sunday we will be hearing from two key trump staffers on their new role in the white house. incoming counselor kellyanne conway and trump spokesman sean spicer. it's all part of the road to the white house coverage, sunday sunday at 625 eastern and 9:35 eastern time. al sharpton will be leading a march and rally in d.c. in honor of martin luther king with a focus on voting rights, criminal justice, health care and economic justice. live coverage on c-span saturday at noon eastern. >> this weekend, book tv brings you two days of nonfiction books and authors, here's what's coming up. saturday at 7:30 p.m. eastern, washington bureau cheap april ryan moderate a discussion on race relations but she's joined by author joanne reed, westmore and avis jones to weaver.
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on afterwards, new york magazine magazine columnist looks at the presidential record of barack obama in his book audacity, how barack obama defied his critics and created a lot legacy that will prevail. he's interviewed by jim acosta. >> i think the future ought to be liberals recognizing the success of this administration, embracing it and defending it going forward the way you do with lincoln and roosevelt. i think obama is the closest thing we've gotten in american history to that kind of successful president and should be defended by americans from the center to the left. >> on 7:15 p.m. eastern on sunday, radio host on the role religion has played throughout american history in his latest book the american miracle, divine providence in the rise of the republic. go to book for for the complete we can s


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