How do we keep people engaged, how do we reduce the burden to require this episode. Right over the years, outed in the program, i graduated from pepperdine. It really is local and that is true for value in healthcare is working. And it is the same on the entire continuum of the country. And we are seeing Health System and the marketplace to be very specific, it is who you are, what your assets are, what your Service Lines are. What your pay landscape is, what is your socioeconomic environment . All of that plays into your strategy. It is real important that thinking about better outcomes, you understand the Business Impact of all those factors in developing your value strategy. 27 years ago when i had a math professor at pepperdine got me a job helping model alternative payment models, doing capitation for a model in the valley and was struck and completely hooked by how quickly when the incentives were changed, provided provide outcomes, it is similar to what we were doing at that time. In that role looking at alternative payment models in the past 20 years and finally the aca has passed, starting to see an understanding is that these things are needed. Lots of unexpected partnerships, hospitals and payers, going to dinner, the cats going to dinner, around the country, really interesting because true anger, people are pets and they are at town halls and people really want that coverage and people who feel the coverage is so expensive. One thing i always keep in mind is the number one cause of personal bankruptcy is a health event so we have a burden upon us to try to figure out clinical problems and that will take the community as well as our clinical settings. Up until now the value has been securely focused in terms of the programs we are seeing in federal and state governments. The key settings in hospitals doing something differently. We know now macro is the first time the federal government is saying we will take individual positions based on this as well so at a Pivotal Moment how we align, support physicians to be able to perform under these programs is really critical. Looking forward to introducing our two panelists theres a lot of change but one thing we all agree on is there is no turning out. The use of data, creating value left the station regardless of what happens how healthcare is financed ultimately, we know the power of driving value. Okay. And the ceo of the mayo clinic in arizona. And start with doctor deco, the chief executive officer at mayo clinic in arizona and Vice President for the mayo clinic since 2011. Has been with the mayo clinic 16 years as a consultant and professor of emergency medicine for the college of medicine. He served in leadership rules like chair of the men mayo clinic of emergency medicine, 20002008 with general responsibilities for the province of mayo clinic in rochester, please join me in welcoming doctor decker. [applause] the chief executive officer and senior medical citizens july 1994. Associated with the Organization Since 1979. He was on the executive staff prior to joining and currently serves as chairman of the American HospitalAssociation Board of trustees and chair of the American Association of medical colleges. [applause] okay. To kick off a few opening comments. Great to be here and i would like to thank our host, megan and our colleagues at pepperdine for having me join you, it is a pleasure. We started the day with a fascinating conversation on the nuances of healthcare but also an overview that i think challenged us to think about the expenditures of healthcare and quality care in the United States. One thing we hear a lot about how bad healthcare is in the United States, it doesnt quite tell the whole picture. I start with a little font exercise. You or a loved one diagnosed with an incredibly serious condition, a rare cancer and you need to get care soon. How many of you are going to book a flight to some other country, book a flight to a different country to get there medical care, anyone in the audience, usually there are one or two because there are much looser oversight of experiment of therapeutic trial, sometimes you go overseas for that. The United States actually enjoys the best Health Outcomes for complex conditions including things like Breast Cancer and Prostate Cancer in the world. And at times fragmented system. And local conversations, and and we dont and hands, and where is the voice of the patient and National Conversations how to reform healthcare, where is the voice of the patient. 1. 3 million unique patients in every country in this union, 140 other countries who fly to this country for their care every year and the things we hear from patients, and and integrated healthcare. They want healthcare that is affordable. Heres another thought exercise. Is it always necessary his excellence and good outcomes always more expensive . Anybody . It doesnt have to be. Many of you are Business People and you know the secret behind the solution to the problem where you want excellent quality and affordability is innovation. We need the ability of healthcare in the United States to innovate and that is something that centers what you are hearing from today. And solutions, the price of colonoscopies, those could be screening colonoscopies. The second leading cause of cancer deaths in the United States, and one that was great. Who wants a colonoscopy . But what if instead of haggling over the price of a colonoscopy, and Innovative Team came up with a totally different solution involving screening for microamounts of dna in your stool so you dont have to have a screening colonoscopy, that was developed over ten years at the mayo clinic published in Clinical Trials in the new england journal, approved by the fda, licensed to a company that is now offering a test no financial stake in that but the Important Message is a fraction of the price of a colonoscopy, increases access screening can result in better care at a lower price so i share that with you as an example of how powerful innovation and how critical it is that the centers of excellence not only continue but we figure out how to help them flourish so we can invest in our nations future with solutions that work. Thank you very much. [applause] extremely well said. I think pepperdine as well, it was nice to be invited back to something. This actually is the best Health Care Discussion of this type. At least it occurred in los angeles in this region so i appreciate being part of it. A minute on cedarssinai. I say that for two reasons. Im a believer in where you stand, it depends on where you sit but it does provide context for the rest of the discussion on value. It is a private notforprofit integrated Healthcare Organization that has a four part mission, patient care, inpatient, extensive outpatient side of things. Medical research not unlike the mayo clinic conducts medical education for graduate medical education, undergraduate physicians, nurses etc. And Extensive Community benefit and Community Service mission. Down to our last 2000 physicians associated with cedarssinai as well is relevant to the later discussion of half of those physicians i what i would call tightly integrated with cedarssinai. The other half are in private practice in the community in one way, shape or form. Two hospital, cedarssinai, delray, joint venture, among ourselves like medical Rehabilitation Institute recently opened in los angeles. Multiple ambulatory facilities in the area, we happen to be the largest hospital in the western United States but we try to emphasize it is not about being the biggest, but the best. It is a combination of what you might call a Community Hospital. In our case the Community Hospital to 2 Million People to 3 Million People in the los angeles area. The largest provider of tertiary services, the most advanced treatment in heart disease, cancer or transplantation, neuroscience, of any hospital in california. With the combination of the two of those things, in terms of our patient mix, about 40 of our patients are medicare patients which makes us the largest provider of Medicare Services in the state of california by almost a factor of two for any individual hospital and a third of them are dual eligibles. For those who dont know those terms the other individuals who are elderly and poor. Also one of the largest providers among private hospitals in the state, which gets to the cost of commercial insurance we will get to a little later. My point is what we do and who we serve has Significant Impact on both how the movement of care affects us and more importantly we hope we are contributing to that movement. Very quickly, definition of terms of a personal standpoint, valuebased care is all about providing the best outcome for the patient in a highquality safeway at an affordable price and most costeffective way that we as an institution given what we do and who we serve can provide. This is something we are firmly committed to as an organization. Frankly to start because we believe it is professional and ethical imperative of the organization but for all the reasons seek outlined in his opening remarks theres an economic imperative for the country in many ways. I would observe it reminded me california actually has been in this valuebased care game for some time. More so than the rest of the country in one way, shape or form, going back to the mid80s and moving on from there. The Affordable Care act certainly turbocharged the movement to valuebased care. Frankly in the way that only big movement by the federal government can when it comes to issues Like Health Care in america given the role the federal government plays in the this arena. The American Health care act being voted on or has been as we speak, frankly has elements to it that raise question about the momentum around that. Maybe we can touch on that later on. Finally, when i think about valuebased care i think of it in three ways, valuebased care at the patient level along the lines with what we have already described but there is the issue of valuebased care at the Organization Level and the issue of valuebased Health Care System as it relates to the system itself. Whether it is at the regional level, state level or nationally. Most of the work to date has been on the first piece of that with regard to the patient level and to get to what the was describing in solving the differential between america and other countries on the cost side the issue of valuebased care at the patient level is necessary but not sufficient to complete the journey without also examining the other two elements. I think the movement to valuebased care is fundamentally connected to having organized systems of care. Organizations and structures that have capital, management capability to bring to bear the kind of change involved in moving the country from where we are to the future. That conversation oftentimes breaks down into a debate about hospitalbased systems or physician driven system. I think that is a waste of time. Lets get on with figuring out multiple examples around the country of organizations, the mayo clinic is a great example, organizations that have their roots on the hospital side, organizations that have their roots on the payer side here in california kaiser being an example of that which started as an Insurance Company as many of you know. Last comment with regard to this question of valuebased care with regard to measuring quality but in particular efficiency. I think we are very early on in that journey and among the things that hopefully will be addressing in the years to come are the measurements of some of those. Thank you. Thank you both. [applause] what we would like to do today is dig a little further into the concept we just discussed with a series of questions to prompt the conversation, specifically there is some conversation about the definition of fee for value. We are moving towards it, specifically in your organization and you can start. Three highlevel components, what is the physician affiliation strategy. How do you create governance if you dont own anything, community partners, give some thoughts on how you are looking at that and we will move into population health. Mayo clinic, we are a notforprofit organization and our model is a little different, it is not the most common model. We are a physician Led Organization and our physicians are employed on a flat salary. We feel for our patients what that does is eliminates financial pressures on individual providers. If you are a patient, it is a gray area, you like the comfort of knowing there is no financial benefit to your Orthopedic Surgeon when deciding whether or not to replace the knee. The fee for Service System is the majority of how we reimburse healthcare in the us we get into valuebased payment in more detail. And make money, not fully recognized the sole solution, and we want to make sure we encourage excellent outcomes. Medical centers can affiliate, we have 45 Medical Centers to share knowledge of. And fees for these relationships allow us mergers and acquisitions you read about in healthcare these days, slowing down currently but the past 5 to 10 years out there have been a huge boon of merger activity and we feel again as a Mission Driven organization focused around patient excellence, sharing our knowledge and own and operate Medical Centers all over the country but there are multiple solutions. That has been our approach. We are different. My opening remarks, 2000 physicians, the 2000, 400 are fulltime faculty physicians who lead advanced tertiary and quaternary services that carry out the medical research and medical education efforts to the institution. We have another 6 endorsed or that are geographically distributed physician network, essentially covers a 15 mile radius around 8700, for those who know where cedar sinai is, a combination of primary care as well as specialist in the physician network. The work, what i observe about that, i agree with the observation that it is not about any one particular model that lends itself to success and im intrigued when colleagues say you employ your physicians, it is easier for you to make change. Im here to tell you that is not true. It is not absolutely true at all. The change process, whether the physician is employed or in private practice has all the same elements that zeke referred to in john carters book and other leadership books. They are more integrated for the institution, there are two differences, and because they are more active in the integrated work of the organization. The process of change related to shared vision and the kind of things the go along and follow from that, the physicians who are in a more integrated relationship move through that change process in some areas more quickly. In other areas not but in most areas they have that happens. The other element has to do with the ambulatory environment, the kind of characteristics you saw zeke described in his 12 prescriptions for American Healthcare in the future. In the case of integrated physicians, virtually all of those are underway as part of our transformation to valuebased care. In the case of private physicians these are independent businesspeople and they are making their own choices how and where they fit in the valuebased care equation. The part we can impact, and to their credit, and great professional credit, private physicians are very much aligned with us with regard to the valuebased Care Transitions with regard to their patients, and the outpatient setting, those elements where there are those opportunities that exist to move in that direction. Depending who you are, you organize in certain ways to drive value. One of the hardest things you both talked about, change management. Can you give us a little bit of insight when dealing with you talk about affiliated physicians as opposed to employees, a similar apps dynamic. How do you ensure the clinical value, the brand of your organizations is protected, preserved and moving towards what you want to communicate to the marketplace . Absolutely critical is this notion of alignment. Every Healthcare Organization has a culture of service. We focus on a single primary value where the needs of the patient come first. Everything we do, our trustees and board levels, we sometimes make those hundred Million Dollar decisions, everything is driven by what serves our patients best. That permeates the organization and when you have that, the financials and even our Academic Mission which is education and research are critical to us but they our research must, we spend 700 million on research including nih funding, it must be driving to answer unmet needs of the patient so every Research Scientist can answer that, what problem are they solving for patients . In education we have a medical school, we are working on creating the most innovative Healthcare Workforce for the future so 20 years from now people sitting in chairs like this understand the Healthcare System better than i did when i graduated medical school and derive change but it is all around a single culture where they come first. More than anything more than any Financial Arrangements or bylaws or anything else. People from cedar, sinai on the recovering strategic planner. We make extensive use of classic Business Schools regarding Strategic Planning and ongoing annual plan and accountability systems to move the organization forward. With regard to the hospital portion of the organization those things in terms of goal setting and alignment are absolutely the same with regard to physician side of the organization whether was integrated with other a physician in private practice. To your point about protecting brand what happens in the hospital setting or the Health System on ambulatory setting, in those arenas it doesnt matter what the physicians relationship to the institution is. That is where the brand is delivered. The goals are very much aligned and from a changed management standpoint i mentioned earlier the differences between private practitioners and others with regard to the inpatient side of things we put in place 15 years ago a whole Leadership Development program for the leadership of the private staff not just the affiliated integrated physicians for the private staff to facilitate the alignment with Large Organizations goals. And and and the various accountability mechanisms, and the line of sight and alignment with regard to what it is we are trying to achieve when it comes to the question of this care. The ability to really drive the change, everyone moving towards the new goals. Im going to shift the value conversation a little bit right now and talk about the concept of population which quickly defines the world, the same conversation. Taking on ownership of the population not financially but through data, looking at people who understand outreach or the burden. And the concept of community care, for each of you, are you beginning to engage in population models . If not, why, and the same challenge everyone has in making sure the acute setting is handled, how do you engage with the community . Our Strategic Focus is on serving our most complex it is a different strategy than population care and community care. We actually do have 70 kleenex and 17 Community Hospitals in the upper midwest. We have a fairly large population, we have a robust strategy around that which we call the male Model Community care. It was fascinating listening to the 12 steps of excellence. I wondered if the speaker couldnt have saved a lot of travel and come to the mayo clinic. We have engineers looking like scheduling, it is great, it is separate from the Affordable Care act, and calling and pushing and driving for over 20 years in the United States. It is about rewarding Healthcare Systems for doing the right thing we are as patients once. This is a shocker, most of patients dont want to be at the mayo clinic, they want to be well and at home so that is the moment that says, as the nation handles and make sausage around the solution for healthcare in the United States, we want systems that reward health and wellness and systems that encourage Medical Centers for teamwork and integrated care so we are focused on this complex care puzzle much more than population care. We feel a crucial part of the puzzle. 5 of Us Population drives 50 of the healthcare costs at 3 trillion we are talking about. Whether it is a population model or a destination care model at the mayo clinic we have to figure out how to take care of the most complex patients. Some folks are surprised but the same tool in the new yorker article also found an area of surprising low cost in the last two years of life which tend to be drivers of high cost care, typically incredibly expensive and that care was rochester, minnesota. Home of the mayo clinic. So excellence in care does not have to be expensive and it is about coordinated care and what is best for patients, isnt always doing more. Sometimes it is doing less, sometimes it is recognizing time for hospice care instead of throwing more procedures at patients. Given you are focused on a certain target you are dealing with a lot of disease burdens. With chronic disease we like to link closely with primary care providers, and we actually have patients all over the United States. A different conversation, a local provider with a and accused episode of difficult cancer, and Nurse Practitioners all over the country. Population health. Art and healthcare mean Different Things to different people with a variety of ways, with ease of simplicity, a significant level of activity for what people think about in terms of health, and it is capitation. And in the commercial insurance side on the medicare side, and another element of population health, and with a specific disease or commonly chronic conditions of one type or another. And a variety of relationships for commercial insurers, and some and at no come to mind. For chronic disease, acl models, the payment model with the kind of performance mechanism measures and incentives to promote valuebased care as it relates to patients suffering multiple chronic conditions and i am pleased to say those are arrangements that emerged in the last three years or so and we had significant success, recognized by and some as having chronic care arrangements generated the most savings in their first year of operations. It is very much a part of how we view the world and the essential element from our standpoint in terms of the payment model being critical to the success of this arena. One of the things we talked about backstage was what it takes to keep a person from readmitting or admitting in the first place goes beyond the clinical and that is the environmental genetics, is there any perspective on how you might engage with any aspects of the community to help improve better clinical outcomes . You put your finger on one of the biggest challenge facing country with regard to solving the cost question and one of the areas of greatest confusion when it moves to the conversation zeke described with Health Outcomes, you have those two sides, cost of care and results and what emerged in the years since the aca was passed is a broader understanding of a reality those of us in Healthcare Delivery have known for quite some time and that is besides genetics, the biggest contributor to Health Status or socioeconomic status and if you were to take those same countries seek had on the slide and examine their domestic expenditures for what we would refer to as the social safety net that goes into a populations Health Status you would be stunned at the difference between the United States and those countries in terms of what they invest. Not bringing that up suggests what is right or what is wrong but i bring it up to suggest when it comes to the question of Health Status those of us in the delivery of care whether it is that ambulatory side or inpatient side, the end of the funnel if you will. We are there to provide the care when the care is needed and we are involved to the extent we can impact the prevention of disease and avoidance of it but in terms of the impact on the last point, what we can do pales in comparison to the other things that drive and individuals socioeconomic status that contributes to their Health Status. I would underscore your comment, they have driven four by individual behaviors and choices and the environment people are born into and genetics. Those are the big factors. Anyone want to gander what you think a nations Health Care System, what percentage, healthcare outcomes of a society, 10 . 3 trillion and crucial, and determinants of health. And things like longevity. A good shift. The conversation around consumers in healthcare working hard to get better value trying to purchase value, buyers of healthcare, what about the consumers, the nation moving toward better understanding really important societal trends beginning to impact healthcare. One is i want it my way. We use to buy a cup of coffee and you could have cream, sugar or black. Now everyone in the room when you order your tough cup of coffee you will have it customized just for you and what we should expect from healthcare is something we are very interested in. How do you interact with patients on their terms . You see apps, portals, ways many, the Younger Generation, they would like to interact with digital devices, not telephone calls, and certain types of things, and Consumer Research for a serious matter, the Younger Generation does want facetoface visit, if you have a lifethreatening illness you may not want to explain that question. And this conversation about valuebased healthcare and how to reimburse it we never should forget the biggest driver is the impact to me, the patient. What are the copays and deductibles. Are we stuck in a Narrow Network that is fine for strep throat but a nightmare when i have leukemia. Those are the questions we need to ask. The movement in healthcare, one of the best things that happened to patients or in the short and long run but also one of the best things that happen in the American Healthcare system, the impetus for change we are talking about. The need for all of us to meet the individual, and what is convenient with all the dimensions we referred to. The kind of things that are driving the kind of changes, as far as the front end process and contact point between the Healthcare System. Already had a substantial change and will be one of the most significant factors that will move us in the direction everyone is seeking. The leadership roles driving innovation, talk a little bit about how you meet your organization through change. And innovation process you are particularly talking about in the organization. We could go for two hours on this topic. A few quick examples, one is we recognize 13 years ago 13 billion of mostly us taxpayer money were spent to sequence the human genome. How many of you in this room, how many had your genome would influence your healthcare. And impacting healthcare yet and that needs to change. We have lost a center for individualized medicine where our goal, we have scientists like many Major Medical centers interested in the cutting edge of basic science, most are translational and applied space, we want to take this body of knowledge out there and bring it to the bedside, Family Physicians and patients on their phones can harness an incredible amount of data. Pharmacological genomics, we developed in a technology that allows 45 drugs to be tested, has 250 and a Company Called one off creates jobs, creates testing. What you find when i have my genome sequence, i will metabolize a common blood thinner, and that means. Instead of the doctor using trial and error and getting a second blood clot and being overtreated, and an and more affordable healthcare. I learned to my dismay that im never going to be tall enough to play in the nba. All kidding aside, because of the similarities of missions we have a Precision Medicine initiative, another thing i mentioned quickly, one is the practice transformation you heard in the primary care practice of the ambulatory network, very much along those lines underway. Using technology, we have very active effort underway using clinical Decision Support, most people know that there is more medical knowledge than colleagues can hold in their head. This is an instrument based on the actual patient data sitting in front at the time ordering various tests and providing them the Decision Support about being sure what to do or what not to do. The board of internal medicine developed a series of guidelines called choosing wisely. This was designed to make sure the things that ought to be done are done but things that dont add value and in some cases are harmful are not done. It gets to that point of waste, this was the First Institution in the country to embed the choosing wisely guideline into our Electronic Medical record system to support physician decisionmaking in the inpatient and outpatient setting. The last example i would give has to do with promoting changes in the payment model. We and six other institutions and Delivery Systems in los angeles developed a joint venture with and some blue cross to create a joint insurance product is one of the barriers to get to valuebased care taking down the functional if not legal barriers that exist between the payer side of the Healthcare System and the delivery side and that joint venture was designed to essentially take down those barriers and promote joint interest in providing valuebased care in this conference and the whole discussion. Can i follow up . And incredibly exciting future in healthcare around the digital environment. Call it the internet of things combined with potential of Machine Learning and Artificial Intelligence and new techniques managing big data and many of you know there are tremendous entrepreneurial activities in these spaces but will transform every industry, it is happening in healthcare. It really is, you shared an example of how we are in the teenager stage. The Electronic Health records that have been deployed are a disaster if you talk to doctors. They are burdensome, expensive, take too long. Survey was just conducted showing over half of the nations physicians are burned out which is a tragedy in and of itself. Human tragedy but it means people are retiring early, redirecting their careers which is a terrible loss of great resource for the country. When you talk to doctors why they are burned out they will tell you among other things it is the clerical burden of the practice and by that i mean how many times do i have to click to get something done . A huge opportunity to do this better, to minds of vast amounts of data and provided to the provider in a way that makes their practice easier and a tremendous amount of opportunity to harness the World Scientific data. It typically takes a scientific advance between 12 and 18 years to get embedded in the practice because it is such a happenstance random process and all kinds of change management philosophies so it gets stuck and what if we could bring on advances forward . We will see a dramatic revolution in how healthcare is provided, which will change everything and if we manage it right for the batter. It is an exciting time. So many questions to talk about. And additional clinical and it was about to get worse when i talked about macro and the federal government, adjusting payments based on whether you could have certain quality measures which are administratively measured. What are your thoughts on how Something Like that would affect physician consolidation or other types of changes in the physician marketplace as more technology is needed and more support connected with practice medicine. I think we have seen how that is playing out already in terms of the number of physicians seeking shelter from the storm is the generic term i would use. After becoming part of physician organizations or joining together in integrated Healthcare Systems and things of that type. It has to do with everything in terms of the fatigue factor and physicians went to medical school because they wanted to practice medicine. When you are in private practice you are in business. The business of practicing medicine. In order to have systems, in the acquisition of the technology, what it means to be in the business of the practice of medicine. Physicians are finding what that requires is beyond the capacity of the traditional single or even small group practice. And so macro will only contribute to that. I think you will also see a curve based on age. For those physicians approaching retirement rather than change their life which i dont blame them, change is good, you go first, that is the old phrase. Those physicians approaching retirement will say to themselves, whatever the penalty is in the early days the penalty is not all that great, they will finish out their career as they have and for younger physicians, mid career physicians and younger physicians i tell you i know where our graduates go. Our graduates, virtually everyone is going in some affiliated relationship of one type or another, virtually no one goes into private practice as that term has been known. Any insights you care to share . It is too early to tell much about where our nation will go with possible replace or repeal and replace of the Affordable Care act. We would acknowledge the mayo clinic, the Affordable Care act has a number of steps forward and a number of complications from a consumer perspective and Medical Center perspective so a mixed bag, definitely an opportunity for improvement. Will the American Health care act improve it . That is to be debated. There is obviously great discussion around how do we make sure people have access to real healthcare blues not just think they have access only to find their deductibles and copayss are so high they dont have access but can Access Healthcare they can afford. My own full disclosure, the year i was chair of the medical Health Association was 2009, the year the legislative Affordable Care act was put together so i was up close and personal. The American HospitalAssociation Like every professional organization on the delivery side, supported the development of the Affordable Care act. I believe that and i believe now that directionally, what it represented was the right thing to do. At the same time which is a message lost when these things are put in place, to me it was ludicrous for anyone to think you could pass a piece of legislation as significant as that is and as broad as that is dealing with an issue as complicated as the American Healthcare system is, and the first step of that, would be perfect. It doesnt happen that way. It was recognized by many people involved in it that was something that would needs adjustment and refinement, with the Affordable Care act, i expressed grave concern. I dont think it is productive, in the health of the country, to lose coverage for tens of millions of people expected using the 10 , would mean between one, and 2 Million People in the state of california. It doesnt make the Health Care System more efficient to just not spend money. And that is a false economy. And the cost of commercial insurance. And california. And what it costs, the gap between those two things, and by 25th . We have the data of an adequate amount and things like that. My point in the context of the Affordable Care act increasing the number of uninsured is going to make the problem bigger. Any thoughts . Tom said it will. The last question i worked very hard on. And on the back of the tshirt, describes the future state of health care. What will it be . For change change is good, you go first. You can take the back. It is a theme that has emerged, leadership matters. If we are going to make the change we are talking about it doesnt happen by accident, leadership matters. The back of the shirt, the future is bright. We have to remember in a democracy there is great and passionate debate, pendulum swings Different Directions over time. A fantastic country that can solve problems, and how healthcare should work, their job is to provide guardrails, to help us innovate and develop solutions that are focused on patients, people, employers and Healthcare Organizations and that is where the solutions lie. I am confident, we talked about genomics, fourth industrial revolution, digitalization, incredible new Cancer Therapies using immunotherapies, Bright Future in healthcare over the next we 10 years that were going to realize and there will be a lot of white noise in the middle, lets Work Together and figure out how to get the job done and i look forward with great confidence. In looking at the future, do you see any solutions in getting with the workforce problem that we are starting to experience both in the medical and nursing professions . The question is about workforce, and so absolutely. We are becoming a nation that actually has tremendous demand for a well educated and welltrained workforce. Thats something most of us in healthcare take very seriously. And so we not only have five schools at the mayo clinic, but we also partner with major Academic Centers that are developing nurses and technicians. But we also believe we should map out a future where not everybody may need a fouryear degree, there may be technical degrees and trainings, and there may be a whole cadre of healthcare workers that tom and i a few minutes before we started were talking about the role of paramedics. But that is vastly expanding healthcare. There may be opportunities to take healthcare workers and give them a Solid Foundation in principle and then retrain and as the future evolves and changes. But we dont want and what we see in all Industries Including healthcare is people getting left behind as they are trained in one area that might get outdated, and if they dont move forward. Your question is a pertinent to the question of valuebased care splash on the cost side. Because the driver, the single biggest driver of why healthcare inflation has been ahead of regular inflation, other then the demand side, the utilization and demand side has to do with the internal rate of inflation that is occurring within Physician Office practices and hospitals to keep, to recruit and retain talented, capable people because of the shortage, whether its in nursing, pharmacists, imaging, imaging technologists, the one down the list here about 60 of the operating cost of the hospital is people. And so because of a shortage, the rate of Salary Increase in the healthcare sector over the last several years, working within the way the system has been funded to date, has been 50100 more than inflation in general. Theres a real catchup effort thats trying to be undertaken at to expand the training programs, education programs, but it will mitigate things but its not going to solve the problem actually. Just at the point in time, by the way speaking as a proud baby boomer, just as my generation is now moving into the time were going to need it. So this problem is only going to get worse. Besides increasing the education pipeline, the other potential solution would be to examine the licensing requirements and educational requirements for different positions. At the very complicated topic. Again, you can do a whole conference on that. But having people work to the top of the license and examining whether people can be given more flexibility about what they can do would also be a contributor to helping solve what if it will be a real challenge going forward. What to each of you think was more advantageous both on the side of the hospitals in the side of the patients, the subsidies received by the hospital for the patients were uninsured before the aca, or having more patients who are insured . So if i may, what our questioner is asking is if you uninsured patients coming to your hospital, you have charity care. If you have patience could now have most states not all have more access to medicaid or medical or its equivalent. As thomas mentioning you fine that Medical Centers are reimbursed less than the cost of care for those patients. I think its a very mixed bag. Depends on each Medical Center patient population. The innercity hospital, a safety net hospital, et cetera. So theres a lot of nuances in how people fared under which scenario. When the Affordable Care act was put together, you may or may not recall, hospitals and doctors and others agreed that they would not, they would assume and the federal government would not be increasing payments to hospitals for the Medicare Program the way it had been projected. That was agreed to as part of a way of contributing to the pot of money in addition to the additional taxes that went into creating the subsidies. Essentially without legislation was passed at a National Level it was a wash, to the point that why it just made. What that means institutionally varies significantly by geography and by the nature of the institution and by the pay mix. Having more people covered by medical and getting paid what unfortunately is still pennies on the dollar, those pennies are better than nothing. In that regard that was helpful. The subsidies, the subsidies i think were more, at the end of the day, had more of an impact on people being able to get some access, admittedly the problems weve already talked about, about what those policies are like in the copays and deductibles. But the subsidies i think had a greater impact on putting healthcare within reach for more people than it could have been before, then it did necessarily for improved profitability for doctors and hospitals. In every other industry, investment in technology has reduced costs, access, delivery time, and this is not happen in spite of a lot of investment in technology. What are the obstacles, and do you see that happening over time . Yeah, my thinking is, one of the reasons that it hasnt been as uniformly recognized as cost savings as a Payment System in healthcare is complex, or reversed, tipping on how you want to say it. So we have thirdparty payers that are either large employers, Insurance Companies or the government, and then you have Healthcare Centers working to innovate by not always getting reimbursed when the panel the second talked about telemedicine, its a great conversation. Its very hard to get reimbursed. We do it because its the right thing. For rural Medical Centers have access to neurologic stroke experts within three minutes. That marketplace makes it harder but there are examples and actually i would argue telemedicine is one, but what i would like to see is a closer linkage of the payers and patients and Medical Centers around figure out when an innovation is reducing cost over all, how to recapture that value appropriate and who gets rewarded. He goes right now its very hard. I would just observe people make the observation about technology and other businesses. Urgently talk about the substitution effect and the ability for technology, the result into people be necessary. We saw in the last election some of the consequences of those advances in terms of how people feel about and whats occurring in, with regard to the adoption of technology that can eliminate jobs. Healthcare is still, healthcare is a Service Business. Its like the Hotel Business in that regard you. At least the hospital sector its a Service Business that involves people. The kind of thing youre describing if it were applied to health. Would involve things that would allow the technology to replace people. I think that beyond that, there are many aspects about technology more broadly that i think has substantially impacted the cost of healthcare. I guess it falls into category if you think its bad now, you should see what it would look like if it had not happened. Let me give you my best example. Its one we hav happen to know t because the people involved in the development of minimally Invasive Surgery include the researchers at cedarssinai. Id like you to stop and think for a minute what the total cost of healthcare in america would be if when you needed your gallbladder out, you came to the hospital and spent seven to ten days after having your chest open or your abdomen, excuse me, im not getting evidence, im not a physician [laughing] its down here. [laughing] spending 17 been days when you couldve done on an outpatient basis, to have your hip replaced and say ten days to two weeks which was average length of stay when i started in the field 40 years ago, and now you can get that done on an outpatient basis. Then theres the other category, i dont think we have no mechanism really to chart the real value contribution of technology in medicine. As a relates to a think the point wyatt was making at the end, and that is whats the value of people who are able, people being able to get back to Productive Lives . And what does that mean for the economy. Thats where the big impact of technology writ large is applied to medicine i think as great, has made significant contributions or i dont know we necessarily measured it particularly well. Can you speak to the valley of hospital medicine in reducing Physician Burnout and valuebased care . Sure, real quickly. I think the development of hospitalist is a real plus on a couple of levels. For individual physicians, especially if you live in los angeles and youre a doctor is trying to get around los angeles to go from your office to the hospital to see a patient, it takes up some of that hassle factor and allows the physician for the own productivity purposes to be more productive in the office. If thats what the satiation chooses her on hospital site if thats what the physician chooses. The Hospitalist Movement has been a contributor to the reduction in length of stay the juicing as well as the points of unnecessary tests. It just has to do with the diagnostic process and the availability of having a physician who, when they get their hands on the information realtime, patients right in front of them, can call their calling, consult with one another and make the decision and things move on. Its been a very positive aspect in those terms. You will hear some physicians appropriately and understandably express remorse that they feel like theyre losing some of their social contact with their patients, that the patient and then feel valuable. That is feedback weve received from our patience as well. There is a challenge to this, and i think the question for those of us in the hospital side of things is how do we overcome the acknowledged change that that represents . I think with time for one more question. With 5060 of all healthcare expenses in ones life taking place in the last six to nine months or so, is that just a function of our system, a miracle mentality, or is a really something to education we can do about that . Yeah, this is a really key question and its a growing topic of conversation in both academic Medical Centers and in the public which is great. I think it is a little bit more complex because we both patients and loved ones and Medical Centers, you dont always know whos going to die, right . There is better data on this. So the two categories. Our mind rapidly goes to the very elderly who is at the final stages of a chronic disease, cancer, and how much do we do there . Actually even in that scenario, we can as a nation, is look at a Medical Centers, to still probably do too much. It might even cause harm or pain. And so theres a very good conversation around this, and should we be wiser about i would say if its your or my loved one we dont want the conversation to be geez, we are concerned about National Healthcare expenditure on your mom, so lets not get that cd. It should be, whats the best care for your mom or dad now based on, lets have this on his compassion conversations. We have a hospice that is on our campus and we provide the medical care for that. Why did does is it creates of this type ecosystem where patients can quickly sometimes at night and weekends and all the rest be moved out of the hospital where theyre not in that intense environment that is designed to intervene and into an environment that is designed to provide comfort. This is a long conversation that we dont have time to go into great detail, but you are onto something there with this question to it something i think we need to continue the conversation and explore. One of if not the most important topic for us to dress as a nation, is a publication i think ill how we die in america. I think im close. If you google that i think it will take you to that, that makes a point about how we die in america and whether or not thats both compassionate as well as costeffective. I would also say this is an area of interest we that at cedarssinai for many years because we treat an incredibly culturally diverse patient population. I would just, and my comments by saying i get to see a more complex matter to be addressed, and address it well that this particular issue. Because it raises all sorts of cultural sensitivities about whether everything they can be done should be done, or not. Very complex. That concludes our time today. Thank you both very much for your time. [applause] terrific insight and information to we greatly appreciated. Tom, we do agree with your comments on the consumers movement and healthcare been critical as someone said hell be an integral part of the future of healthcare symposium next to which you will hear more about later this afternoon. On behalf of the healthcare subcommittee and pepperdine university, megan, we want to thank you, and wyatt and tom, we want to share with each of you a token of our appreciation. Thank you very much. Thank you. Thank megan north and tom and wyatt again for their presentation. [applause] if you will hang tight for just a moment for pictures. This weekend, cspan cities tour along with help of our Comcast Cable partners will ask for the literary life and history of eugene oregon. Saturday at noon eastern on booktv go inside university of oregons Library Archives and special collections for look at the life and writings of the author of one flew over the cuckoos nest. After the book was published, a psychiatrist named Lewis Bartlett read the book and he sent a fan letter. There ensued a sign corresponds between the two of them about mental institutions, psychiatry and those kinds of details. So theres a real conflict when africanamericans then came home but there were welcome in their home communities. In terms of the effects of the war in terms of form how americans thought about race relations, i really dont think it did. It didnt have the impact that africanamericans had hoped it would. On sunday at 2 p. M. Eastern on American History tv, the story of Abigail Scott dunaway, and oregon pioneer and womens rights activist. She is an example of one of the really great diaries. She describes whats happening between the people. She describes troubles that happen. She describes the landscape in the scenery, and its clear. I mean, you get a pretty good inkling that shes a really good writer, you know, and that served her well later on in her career as a leader in the suffrage movement. And give a former oregon u. S. Senator wayne morris. He was a bit of a curmudgeon. He was a man of high principle and if you didnt have the same level of principles and integrity as he did, he would be vocal about that. He was very critical of other senators. He stood his ground turkey wouldnt compromise sometimes. So i think at times people were trying to move it along or became frustrated in dealing with them. Right in the end i think he is so well known for his integrity. Watch cspan city tours of eugene oregon saturday at noon eastern on booktv and sunday at 2 p. M. On American History tv on cspan3. Cspan3. Working with our cable affiliates and visiting cities across the country. Coming up and about 45 minutes live live coverage of a discussion with a university of California Student who have organize a speech by ann coulter on campus. The speech was canceled, reinstated and canceled again this past april because of campus protests. The discussion hosted by the Education Writers Association conference at 9 a. M. Eastern. Before that a briefing by va secretary David Shulkin from the