Did you even get to become an architect . What was your path . Acerbic medical school. So i was in medical school and not very happy about what i saw around medical school that we were feeling at one of the most frustrating aspects when i would work in the emergency room as a student that we take care of this patient who had heart failure, difficulty breathing, we work hard to make sure the patient was what we called dried out to the excess fluid was taken down and everything was turned out perfectly. Inevitably, he or she came back six, seven, 10 days later and we had to do it all again and we were not following up one patient in the hospital for six weeks for back to endocarditis. Send the patient home in two weeks later back in and it was extremely frustrating. I also than what to do a phd in political theory at harvard, thinking that i would at some of this was sort of the values of the health commissions. So i worked on endoflife care, physicianpatient relationship for a while. Then i came to the nih and mark don research ethics. As i was seen the end of after seven years i decided i should turn my attention to resource allocation on the Health Care System and be a Prominent Health economist from stanford and whenever im in Health Policy is depressed about theres going to be no comprehensive reform were thinking over the comprehensive reform would want to have developed a voucherbased system and that got me into thinking much more about Health Policy and then when president obama won any appointed peter orszag as head of the office of management and budget, i knew peter from a lot of conferences and meetings can i email him and said peter, you need needed doctors who help on Health Care Reform. He said lets talk about what that an arrangement for a work at omb assisting. As far as the problems with the aca, which you do though perhaps the first half of the book to comment that you set out to fix, collectively, can you outline those . The american Health Care System as i say sub title is terribly complex. Are the Affordable Care act will improve her terribly complex, blake on just reinventing American Health care how the Affordable Care act will improve our terribly complex, blantly unjust, outrageously expensive, grossly inefficient, error prone system. The Health Care System and to does make him a thousand nine saw the same spirit is incredibly complex, still trying to explain to people was paid for through insurance, medicare, medicaid and takes about 40 pages. I dont even go into all the details. The next and how doctors are paid, hospitals are paid, with the incentive structure is, what the regulation for curt says, devices. All of that is incredibly complex. We were doing well. 50 Million People were uninsured. Yet uneven quality. Some academics are fantastic outstanding quality, that pretty uneven. Millions of people who have high blood pressure. Not hard to diagnose, not hurt to treat worried theyre not diagnosed or inadequately treated and we know that increases your risk of stroke, Heart Disease comest shortens your life. Before we pass the Affordable Care act, one in 20 people at a hospital acquired infection. Tens of thousands of people died and then there was the cost taking ever more of the economy, making states tradeoff between medicaid and education, making individuals get Health Insurance by keeping wages low. Lots of reasons to change the system and i explained all of those. Anyone of them would be good enough. Having all of them, i dont think theres a republican or democrat in the world in 2008 at 2009 who would say its great. Really by 2008, 2009, almost everyone agreed we had a system that was broken and needed repair. The question was what kind of repair. You explain that very, very clearly. The Health Care System is a daunting enterprise. Its incredibly clear. Whats interesting in the beginning is history, i guess you could go way back, but started mixing a worker with the clinton. Were no surprises as i decided to lets give people a feel for how long weve been trying to change the system. One of the surprises to me as to engage how republicans work in 1945 the governor of california at that time, earl warner, propose comprehensive Health Care Reform and he came within one vote of getting it passed in california and he had gotten sick and said we really need to protect people from the cost of getting sick. When nixon got a late date in 1946, one of his first legislative dose he introduced was a bill about comprehensive Health Care Reform. Heres the crazy thing if i describe it, no think man, did he write obamacare . Was he one of the architects . He wanted to give subsidies so that they could go and buy private insurance. The government would provide the subsidies. Sounds a lot like obamacare to me. He proposed that and when he was running for president in 1960 against john kennedy, there was a big day. Public and the democrats trying to figure out how to get people left out, poor people, especially the elderly, how to get them insurance. He reintroduced the idea is that it is for people to buy private insurance and when he gets president in 1973 and 74, hes negotiating as president with type kennedy in the senate and wilbur mills in the house about how to come together on a comprehensive Health Care Reform bill. They were this close to it though that they could agree to and in typical washington arrangement, scandals break out. Wilbur mills has learned exotic dancer falls into the tidal basin. He is forced up the chairmanship of the ways and means committee. Watergate overtakes nixon and it all goes poof. We actually need to say liberals and union at that time did not want to have a deal that would have private insurance continued. They wanted single payer and were resisted to making a deal with nixon and they withheld their support. If that a combination of scandals, which put the kibosh on this bipartisan agreement with the union and liberals opposing it. For 20 years, until bill clinton, we didnt have another reform. And then clinton comes in and wants a sort of marketbased reform, proposes his Health Security act and unfortunately there are lots of other things with a single focus on it. He had to pass a tax increase. They had the bill. At the time all the rest of the stage was clear for health care, opposition had gained and defeated the bill. We didnt get one bill passed out of committee. 15 more years until 2008 in the system had become so onerous we needed reform and thats when i called the passage of the Affordable Care a world historical act. It did take 100 years in america and this will be the framework for the next 20, 30, 40, 50 years. Well, i think it might be fair to say the most interesting part of the book of course is the fact you were there at the revolution. This is what he saw at the revolution. In addition to the run up when you devote a good portion of the book to that, it is a very Good Foundation again that when i showed this to people as they say where the steep part. Chapters eight through the rest of it where you talk about your own observations and insights as someone who really was very new specifically talk about the complex interplay between policy, politics and Interest Groups. If you would elaborate on that and maybe focus on, at least our bucknell park is because thats one of them are easy once to understand. It does illustrate that its not nearly as cool as people laid out to be. So going into reform, i wouldve thought getting malpractice reform was the regional country and reasonable chance. First of all companies should also be modest in the expectations going in. This is something regulated at the state level. Its not regulated at the federal level. Could malpractice reform legislation is not going to solve a problem. You cant force states to do this in this way so we could provide scientists another structure. We had a very good combination of arrangements that made it look likely. The president himself was for knockout this reform. He had written an article in the new england journal of medicine coauthored with Hillary Clinton before he declared for president , advocating for malpractice reform. He thought this was an important issue. There were two doctors in the white house. Myself about cochair. Both of us that malpractice reform is a good thing to do. Other senior advisers, Larry Summers and peter orszag thought it could encourage quality care, can encourage doctors to focus more on quality. So we had a good arrangement. We studied the number of options and as i tell it in the book, we have laid out nine different options and pros and cons. One day in the summer of 2009 as we are putting various things together, they go into their brothers office, which i tended to do to the end of the day if i went in at all and he wants some piece of information about an east affairs Insurance Options for me and i was supporting acts in and then in his usual place as to what else are you doing . I began to explain the malpractice and then he basically said password showed a period we are not doing that. He explained to me why we are not doing that. And the ama, with the same public, they are talking about what they need out of this bill and cutting the sausage of legislation. They never talk about malpractice. All they ever talk about is basically how medicare pays doctors. They want a fix of doctors can get my money. They never mention malpractice. I am not certain its because malpractice will require some of the Democratic Base and if i dont need to defend the Democratic Base to keep the doctors on board, im not going to do it. Either way, no republicans are coming to negotiate. If they said our support would be no pack is, we wouldnt have done it. But that wasnt the case. So here you have a situation where on policy grounds the white house was for malpractice reform and we had to buy some reasonable proposals. But the Interest Groups, the ama and the politicians, republicans perniciously. People say no, no, no, but thats the way it wind up if either the doctors had said already, we understand panic, but heres malpractice. We have to have something all malpractice republicans they will negotiate with you and heres the things we need in the bill, it wouldve happened. But thats not the way i find out. Nonetheless, the president had two elements of malpractice that he pushed. One in a september speech to the joint session of congress. He set the outcome was that a Pilot Program on Patient Safety and we are going to make grants available to improve Patient Safety through malpractice reform. More than 100 million. The Affordable Care act contains a provision i think 10607 if i can remember correctly that says we would give grants to states to reform their malpractice laws and study to and see how it affects care and cost of malpractice insurance and cost of health care. The president obama, more committed to malpractice reform than any president actually did two pieces of a Pilot Program on malpractice reform, more than anyone else. You can say he wasnt committed to it. We didnt get more comprehensive reform. Im disappointed, but main Interest Groups and politicians needed to support it with there in the clutch. As a clinician, this interests me a lot. Just to pursue it a little bit more, you have a very interesting fact here supported by several studies, which i admit that most people who really are the victims of arafats and the vast majority of malpractice lawsuits are herbalists. Your preferred approach as i recall was a safe harbor kind of strategy. Its a little bit about that. Its very interesting. One of the things i point out in the book is no one should be happy with the malpractice system. I dont care whether you are a doctor, patient, hospital, lawyers, its broken. It doesnt do anything is supposed to do, which is to incentivize stock durst not to create errors, comment a patients, and make sure its done efficiently without a lot of overhead cost, doesnt do any of that. Theres not a simple theres not a single metric unit of measure the malpractice system on where it actually succeeds. I think patients as well as top durst want to perform and some people want lets just cap how much we pay unless pretty short statute of limitations on some of. I dont like those. In some ways behind of the most good. Rv was let these this as an attentive to improve the quality of care, make doctors figure two guidelines, so we basically try to think of a program to recall safe harbor. If doctors adopt Electronic Health records and adhere to the guidelines for treatment of the patient, they are presented it is a presumption, which could be rebutted. They are presumed to be innocent. They say. Is it a patient comes in with simple head trauma you normally wouldnt do a ct scan. To protect my bottom from a lawsuit i do as he teased him. In the safe harbor says if you follow the guidelines of patient qualified, you would be in safe harbor and present to be innocent. That seems to be the way to go. Again, incentivizes using adhere to guidelines and thats exactly what we want to her studio. So we prefer that. Other other alternatives . Yes. I dont think we have enough research for the optimal system. The university of michigan has pioneered to say youre sorry, which is admitted to the patient, propose to them a simple solution according to a very sad schedule if the cosby laceration, heres what we are going to do. That has substantially reduced the number of lawsuits. Its reduced the payments. This reduced the time to read all of it in cases. So that looks promising. Again, we dont have enough research. Okay, thanks. Lets move on to the actual aca here. As january 1st rolled around and things went into effect and some stuff what writing some stuff went wrong. So talk a little bit about what we pride and then well talk about what went wrong and how that can be fixed. First of all, the Affordable Care act is more than just big changes. I think it is very unfair to say it just came online. The fact is right after passage in march 2010, lots of pain take my mind. Many people should remember, although they mightve forgotten the idea that young adults up to age 26 can stand their parents plan to effective on on monday september 2010 and Many Insurance Companies made it effect is before six months of passing you similarly, theres been a provision to encourage hospitals so patients on medicare or 20 theres a 20 chance of a return to the hospital within 30 days. They created a program in the Affordable Care act to actually worry about what happened when patients leave the hospital to make sure there is continuity of care. That went into effect. The patient better Outcome Research institute went into effect pretty quickly after the bill. So we didnt wait until october 1st, 2013 in the opening of the exchanges for the Affordable Care to be implemented. A lot of those provisions went into effect in some of them are very successful. Some of them were disappointed to be perfectly blunt. I dont think the Research Institute has been sufficiently progressive in the studies that have been quite timid and we been trying to push back to undertake more compared it 30s. Is that located at hhs or other universities . Independent, private, notforprofit funded by an assessment. The board is nominated to the gao, Government Accountability office so it is independent and not part of the government. Adiabatic correct. The basic idea would be subject to political winds. Is scott until 2019 and i think they unfortunately have not undertaken the right to compared the effectiveness research. They spent a lot of time worrying about the information and getting the basic information about which treatments work better, whether we ought to give this kind of treatment is surgery compared to medical treatment for a particular illness yet again, they havent done enough of that. Nonetheless, in the larger context, the bill is a remarkable impact. Let me mention one other program. The partnership for patients in 2010, what is called innovation is in an effort to reduce hospital acquired shows, errors, surgery on the wrong part of the body and threeyear major program, preliminary data are very, very encouraging. More important, the major problems like ventilator assisted infections are central infections have gone down by 15 . Thats a remarkable a private hospital and i think it shows you what can be done. You are very transparent in the book about a month the problems with the website and the rollout. So who do you think at this time, who would you consider so does the losers in the environment right now and what can we do about that . I think the American Public unfortunately execution on the exchanges, the federal exchanges was not implemented. I think people would use the word he asked go, disaster. It really was terrible. I tried hundreds of times and many other people were frustrated and it didnt have to be that way. The most important issue to me is look, we know it could have succeeded. California moderately well with the rollout. I think it wasnt properly managed. In outcome would just sigh zionists came in, we had a reasonably confident team to come together to fix. Shows you could fix it. Why do you think it took so long . Ui really, refreshingly transparent about the dynamic of the group in admitting an outsider and someone with managerial skill and health care, Health Insurance experiences. Why is that resistant . I can fix lane wide, but i do know if you like, for example, the two exchanges but i think have been really better connecticut and california. Its just that connecticut has a Health Insurance executive who runs it. Its a cause i private arrangement. Massachusetts when they set up thousand six, at a Health Insurance executive. These are people that understand what they need in the marketplace. They are waking up every day and seen how do we make the exchange better and make sure the Insurance Companies operate and get the right information. How do we make sure that the shopper has a good experience to get the information they need in a reasonable amount of time. You see those places are constantly tweaking. They are running it like amazon. I kept saying that. Not just, lots of other people, but so we need to aspire to. Its got to be an amazon like Shopping Experience for people. Maybe. Right out of the box. Amazon didnt become amazon overnight. It had methylation thats been out there for nearly two decades. And so, we need to have that kind of a lot less focus managing an ecommerce website. I think we can structure it that way. We structured it in the old way. This is not a government program. You have to attract customers. You have to make sure they are satisfied. You have to give them customer service. Very different than talladega. Again, i just hope that is the mentality that takes over. Once you have that mentality to the American Public will love shopping for insurance on an exchange. Will see if maryland can manage to catch up. Were connecticut now have said look, we think its got a very good record. We are going to consult and provide that package to other people. You dont have to reinvent the wheel. Some of the state said it signed up for the federal exchange are saying can we take the connecticut thing, put in place of the federal exchange . That would be good. Host makes a lot of sense. You also write here, this is probably one of the more sensitive part of the experience one of the president believes was that the public should be up to trust what he said. Clearly this took a big hit if you want like your doctor you can in premiums will go down by 2500 per family per year. Those things didnt come to fruition completely. The Public Perception, we can agree that Public Perception did agree with that violation of the polls to reflect that. Just a bias, if youre going to go back in, i dont know if it would even go back and it offers a chance. First of all, it is import yes the Public Perception is didnt follow that. Let me make two points about that. The first thing is the president , in dealing with him, we say how does that square with what i said on the campaign . How does that square with what we said in speeches . He takes this idea fidelity that the American People shouldnt trust what you said. On the notion you can keep your Health Insurance plan and people say now, that was violated. Heres why i dont think its violated. I do know what we were thinking, which is there is nothing in the Affordable Care act that says you Insurance Companies have to throw people off. You keep the same plan. No one has to be thrown out. Individuals are going in the exchange. These individual plan a going away. Theres no growth here. It is true that the marketplace changing and responded to that, but Insurance Companies decided they cancel the plan, not the Affordable Care act. Theres no reason why it says you must transfer this plan. I dont accept the premise. The public that somehow we didnt adhere to that promise. Right now we have to go and have a Major Campaign and explain to the American Public the benefits of the Affordable Care act and i think we need to be quite honest about it. This is one of the frustrations. Implementation of a complex bill in change in the american Health Care System is going to be a bed of roses. There are going to be ups and downs. Lets put that on the table and seven changes are going to lose on the way to a better team. A better system will be much better on all three matcher. Access to insurance and care, and cost of the your periods. The fact is on each one of those metrics to party had access in the american system and will continue to a success. The last witness who could save every familys been a 2500. First of all, that is not tomorrow. Second of all, it gives the background of Health Care Costs going up at like 4 greater than the growth of the economy. The cbo has pointed out, look, premiums have been a lot lower and they are a lot lower the exchange than we are calculated in 20. Yes, inflation has come down. Not all that is the Affordable Care act. Part of it is the recession, part of it is the Affordable Care act. Whether it will turn out to be 2500 at the end of the decade as project did, we will see. That is the basic case of people have saved money. Let me give you a concrete example. If you look at medicare beneficiaries, their premiums for the drug nsa program and part b have in fact stayed relatively flat. Im talking about pennies differences. Not tens and 20s of dollars. Relatively flat over the last few years. Thats because of the Affordable Care act. That is because Health Care Costs in the last two years have remained flat. Those people are seeing the benefit. They are paid the same despite inflation and the rest of the economy. So i do think there is benefit. Hi white house with either strategic and pain, not just to get people signed up for the exchange, but explain to the American Public, what are the benefits how the laws done . My frustration thats never been done coming even going to 2009. We never had a concerted, Long Campaign education process. I dont think its that complicated, but ive been frustrated and i say pretty clearly in the book at the two good wins there really were a problem is never comprehensive Communications Strategy and never executing on the loud once we enact today. Postcode now i know you have a day job. We didnt mention that. Guest and vice provost of global initiatives and also chair of the department of radical ethics in health he at the perlman school of medicine at the university at living it. Postcode so you are busy. They just fantasizing, would you have her would you go back if you were called to help tie up loose ends . Guest as you know, my government and its experiment to government was slanderous attacks as wanting to create panels, all of us were shown to be completely, totally false. I love actually been in government. Despite all the hardships, trying to improve the system for the American Public. I know a lot of people who intersect with the Health Care System and how frustrating it is when youre a doctor seeing some of the inanities of the system you are frustrated and at least give them a skill set, one of the things i could do was to think of policies that i think would have the likelihood of pushing the Health Care System and not to us in the right direction. If people think my skill set can help, id be happy to go back in, knowing all the downs that being a government survey, including the personal attacks you endure, even when they are false. That is minor compared to helping the American Public and improving the system because that is something that will last for generations and that is site inc. Really important. Either way, one of the things that motivate me is the american Health Care System is so expensive, so much money, it really influences our debt and influences state budgets. One of the things that motivate me as, look, i care about future generations. I care about the education our kids are getting. The best way to fix that it turns out is to reduce Health Care Costs because what is driving the longterm debt in this country is high Health Care Costs. What dry states to take money away from college and primary and secondary school, high medicaid costs. Given Health Care Costs under control frees up resources for paying down the federal debt premises being able to support primary and secondary education. That is one of the reasons i motivated to do everything i can, whether in government or not to improve the Health Care System. Host lets go from very large board to very contained. He said he loves working in the white house and i can imagine during this time can a momentous, revolutionary as the word used. But its an average day like for you . Guest an average day day i must always start with a team meeting with or a sack. It became a little more civilized. Early on it was when we met regularly and it became more civilized and then work on whatever task it is youre working on, whether its the provision of the bill are in my case i had the pleasure of working on the first ladies lets move initiative and help crafting that. I also is working on Global Health issues and youd have other meetings on those things and at the end of the day, a recap. Host which for you is 11. Guest no, no, the thing about working in the white house is not so much that the days are long, that the insertion to get some of word thing can happen at 10 00 or 11 00 at night that you need to sit down and work on. That unpredictability, the inability to control your schedule is the worst aspect of Public Service at a very high level. That is i think most people will tell most of the psychology researchers and economic researchers will tell you part of the key elements of happiness is being able to control parts of your environment. Once you work in politics at the white house and policy development, that control completely disappears and that was the most frustrating thing. It is the lack of control. But on the other hand, youre trading off. Can i make a big difference and can i help push the system in the right direction . That is an honor. That is a deep honor to be able to have that kind of impact. Host speaking of the right direction, the end of this month, this is march march 31 is the time at which they will be yet another accounting i guess midmarch of how many folks have read march 31, and evoke in a moment. Just as soon as a measure of how many folks have enrolled and i know you and others have said that the exchanges, which obviously need to spread the risk around, primarily through the enrollment of younger, healthier people is incredibly important in the estimated need for enrollment was about 5 million to 7 million. Where are we now . What are the prospects there . Guest so, here we are, early march, last members about a week old now had 4 Million People enrolled, with the end always has a high bomb in the enrollment period. My best gas for people is between five and i put a million enrolled. At the moment we are about 27 of the 4 million who signed up our young people. That percentage is likely to increase as we get closer to the end because they are the most people sitting just below the 7 million predict it. It is below what was expected. Nonetheless it is enough and enough young people at the risk pools, as it were, the balance between how cusack is probably going to be okay. So we are not going to see a lot of Insurance Companies exit the market. It is unlikely to be great shot of premiums going up. I dont think anyone can be happy with the target. Again, this is between the end of march and october 1st when it reopened. You know, this is another opportunity to improve the website, to get the experience, to advertise, to educate people and get them involved. People will by that time have experienced their 1040, a question of do they have insurance and the notion that its really their obligation to get insurance and if they dont have it they will begin paying a penalty. Over the next few years we are going to see a ramp to us more and more people in my own personal view is that the estimate by the Congressional Budget Office and others, again by the decade we will have many more people than the 25, 30 Million People they estimate getting insurance. Host okay. A few months ago, weeks ago there was a new Health Care Proposal on the block. The pair hatch coburg as an alternative to the aca. If that werent if that were ran in 2009 coming to you think the area of Health Care Reform wouldve been different . How . Guests gathered his people at cspan only remember there was this bird hatched coburn proposal because no one else that they are the day after it got announced asserted. Part of the reason it disappeared is because it is a proposal that is bad for the average american. I did a column in the New York Times story said all right, lets take their proposal if youre the 28 income tax bracket, that proposal needs 1500 additional tax exemption, not something that most americans want to run out in due to get the same old insurance. So it is not a good deal for the average american. This is what i cant get. The core of the obamacare proposal in terms of access to the exchanges will have a marketplace. Private insurance are going to offer them compete in four tiers. People are going to have subsidies and individual consumers will decide which insurance product they want that fits best with their need to and the hudson incentive to have cheaper plants. That sounds very republican to me. It sounds very bipartisan. Very market oriented. What happened here is the democrats said look, republicans have reasonable idea. It may not be our first choice. But we can live with that marketplace orientation with private Insurance Companies offering plans. Lets embrace that. Republicans said they are taking it. We dont want anything to do it even though his official airplane. Theres no republican plan that makes any sense that can address the issues of quality, cost and access altogether. I think republicans have painted themselves in a corner. They dont have a coherent alternative player and every time they offer a plan for this latest per reaction, it really doesnt work. Thats because the republican plan that does work is called the Affordable Care. Host my colleagues back at aei. Host guest , he didnt have an alternative plan that was spelled out. It turns out he wanted to make cement obamacare. I think that is the true republican plan. This is a marketplace. This market oriented. It does have private insurers. That is really the republican approach with subsidies and people. So thats the plan. Richard exton originated. I think republicans not to accept this as a freemarket proposal and say thats the structure. Right now we all know there are things we begun to improve the Affordable Care act. We should just get on with trying to do those. Host just enumerate some of those. Guest is a chapter the book about Health Reform 2. 0. The chapter before it megatrends. These are things like i would like to raise the cigarette tax. The cigarette tax, you raise the cost of a package of cigarettes you can get a very predictable to climb in smoking. Everyone wants to have fewer people smoke here thats good prevention and the most effective way to do it. Host cant smokers be as eligible is the wrong word, but susceptible to a 50 increase . Guest 50 cents per pack. Host no, i meant their premium. Is there a penalty . Guest there is an ability for the Insurance Company to charge people 50 more if they are smokers. But that is so delayed from your smoking and it doesnt help me by the path. One thing we know for behavioral economics if its got to be immediate, not just in. Fifty cents on a package of cigarettes is much more immediate and we know that would decrease smoking 3 . So that is one thing to do and and i think everyone would agree thats bipartisan. Certainly smoking is one of the most harmful things, whether as Heart Disease or cancer. Second, i think one of the most important things for cost control and increasingly the doctors and hospitals want to change and payment feeforservice system. I propose in the book a set of things called about events where you put all the services associated with one medical treatment like bypass surgery orthopedic surgery or cancer care into one payment. To measure the quality of care and give people that pay them. They do good quality of care, they can share the savings. With our programs ready to go. We should throw them out across medicare and experiment with other programs, for example as a mention in cancer care. Second third, competitive bidding. Or the affordable to this proposal would have the marketplace, competitive eating for oxygen equipment, hospital beds, wheelchairs, what is called durable medical equipment. Better that the marketplace at the price that medicare decide we are going to pay this summer. If anyone in america believe the government set prices . No pair has had a competitive marketplace. The Affordable Care act has that in the limited experiment to be rolled out by 2016 and in those experiments we . Thats a lot of money and escape seniors a lot of money in not having to do the copays. Why do we expand that, well about nationwide. We could begin next year in 2015. Second, we can expand to other medical services, lab services and we should begin to use there. I propose in the book, without Business Group that oversees a period when she loved to have this kind of thing run by the head of acquisitions and products for walmart . Poser people who understand oxidizing quality. I think those are three proposals that could quickly be implemented, have a big impact on saving money and improve quality. Host getting to predictions, you had an article in the new republic, about how you see insurance come these evolving. Guest yeah, yeah. The first megatrend of the book is end of insurance come means as we know them. Theres no better line for a politician to get applause and bashing the insurance come to nice. I often dig sometimes its fair and sometimes it is unfair. We are little indiscriminate, but there cannot most favorite part of the Health Care System is first to American Public is concerned. I think ill have to evolve. Competition in the exchanges is going to force them to evolve. Now why do i say that . Weve got growing health systems, whether its the Cleveland Clinic court in massachusetts the partners that the mass general in the brigham hospital in my area the Hospital University of pennsylvania has a growing number of affiliated hospitals. These systems are able to take care of patients in the doctors office, the hospital when they go home in the nursing home and the Skilled Nursing facility. Soon they will begin offering products on the exchange. They will begin adding an insurance function, managing the money to providing care. So they will become what i call it integrated delivery. They will look a lot like kaiser or group help and they will be competing headtohead with Insurance Companies and theyll be taken the profit insurance can just get invalided into their operations to offer a lowercost plan was pretty good read recognition. We all recognize these premier brands. Hospitals and doctors. Power Insurance Companies going to respond . Theyll have to respond by also developing not just insurers, which takes the premium pay the doctor. They will begin watching as well. So i noted the books in early two roles of the system call care more, with wishes and insurance to seniors as the managedcare arrangement, but very high level of the relatively low cost at 20 off the usual payments. Wow, that highquality low cost arrangement is trying to figure out what the secret dioceses and spread it to the other arrangement. Similarly united as this group may have now employed 5000 doctors. Again, i think they are getting into the provider arrangement. You will see this evolution of hospitals adding the insurance function to offer integrated Delivery Systems and insurers offering to provide care and the traditional Insurance Company going the way of the dinosaur. Not going to happen overnight. Its an evolution of the next decade. As i predicted in 2025, that is where a lot of these Insurance Companies are going. Host those are called i dont think you mentioned the term for these integrated systems but Accountable Care guest yes, Accountable Care are really part of the Affordable Care act and i called them sorted intermediate species in the evolution of the Health Care System because they think they are bit like the neanderthals, which is they are there. But they lack is the Insurance Risk management function. When you add back amid their integration to send the integrate the insurance function of the Delivery System and care for the entire continuum in the outpatient and inpatient to Skilled Nursing facility rehabilitation hospital. That is where we are going to go increasingly. Host one of the ideas that youve spoken about and frankly everyone at health care has spoken about for a long time is making Information Available to consumers. Granted its challenging enough to know what parameters to measure and how to represent them, but then how to read and understand them if they are well presented and well measured. How do you envision not working . Guest this whole idea of transparency of prices and quality is definitely going to be key to the future. Right now we know, almost all of us that we dont have transparency prices and we dont know how much is that colonoscopy going to cost, how much is the mri going to cost . The list price, but the actual price we are responsible for reInsurance Company is going to pay. That transparency is going to calm and one consequence has Insurance Companies say to people, we are going to pay. Heres a reasonable highquality pace and heres the price. If you want to go some place that charges more youll pay the differential. The question as to make any good quality or slack . Thats what we want to know. Measuring the quality is a little more challenging. We dont have the best Quality Metrics across the board. Getting a public end not just which hospitals surgical facility, the witch doctors have quality will be the challenge for the next decade. Could resolve the problem . Absolutely. We would get a match of the day just to private insurers and again a lot of money could be made in developing to the public and i think youre going to see a lot of smart, smart people working to develop them in some of them will begin going to become public come to nice. That is actually going to be a big growth area told that the the system more efficient. Once people know what good quality isnt reasonable prices are, ive got to believe they are going to respond to those incentives. Host you are if nothing yes. We only have five marmot left, so not enough time to go through the list in depth, but it is very interesting and we should mention five other trends. You mentioned Insurance Companies as we know them and this one than i am interested in how that vip care for the chronically ill and mentally ill. Thats a challenge. Guest right. 10 of the population uses two thirds of the dollars in the Health Care System. As for the quality problems are. Thats what the costs are. Every Health Care System will improve its quality and focus on those people with chronic illness who are using most of the resources. From what i can see around the system, the best place is to cut the expense about 20 and an improved quality of care. Once theyve sort of got a system in place, the standardized care processes attending to people at home, preventing them from getting sick and going into the hospital and have saved a 20 look for the next way they can save money. Turns out almost everyone agrees, although the group of Health Policy people and Health Economists had looked at this as an Mental Health. It is not in a very severe schizophrenic, but the depressed patients come to severely anxious patients whose doctors system to suit their anxiety. Host personally, i think we know how to treat the most severe mentally ill. There is a darn distributed services we can use them in conjunction with the civil system. So theres a lot to be done. Host i agree. As a say in the book, by the end of the decade of the system begin focusing on improving Mental Health and will have parity between physical and Mental Health because people realize that is the way of improving quality of care in saving money. Host countdown to emergence of digital medicinenet closure of hospitals. Host guest , we will see more wireless monitors. Take a picture of a rash from the senate to a dermatologist. You never see you, but they can diagnose it, tell you whether its a very effective going and you need medical attention or just give a prescription. Monitor glucose every day. That is going to be very, very big at the end of the decade. Host i will mention the other two bits they the end of employersponsored Health Insurance, and of health care inflation. Finally, transformation of medical education. I find that very interesting. Host im frustrated by the fact medical education was a hundred years ago despite the change in how we deliver care and i dont think it is kept up in any dimension. If you look at the time it, we too long. We could train them in three years in medical school is supposed to four. We can do it more efficient job in training specialist. When i was an oncology treaty, training to become a cancer doctor, we did one year of clinical work, taking care of patients, learning how to take care of breast cancer, leukemia and all the rest. Not many of the state and research. You dont need three or training if all youre going to give people is one year of clinical care. 15 , 20 going to research. You dont need to train everyone. Similarly, what we teach needs to change. We need to have more management, learning how to work in teams. After all, the future of health care is teambased care nurses, nurse practitioners, pharmacists, dietitians, physical therapists. Similarly, when you are a resident, were you trained . The future of medicine is not in hospital care. It is in care at home, in the nursing facilities and we need to train doctors and outpatient care. This is a comprehensive revolution in terms of how lottery ticket, where we are training people and what we are educating them about. I see that happening again. Medical education hasnt been changed radically 100 years, but the next decade and a half will be a big change. Host thanks very much, seek. Here are reinventing health care. It really is a tour de force. Guest thank you very much. Appreciate it. Welcome to book tvs coverage of day two of the 2014 Los Angeles Times festival of books from the university of southern california