Transcripts For CSPAN3 Health Care Policy Part 2 20170114

Challenges for American Health care. This is about 90 minutes. Thank you all for coming back after the break. Appreciate it. Hi. Im david im the ceo of specific Business Group on health. First i want to thank them for sponsoring this meeting for us. It is across many points of view they have a strong stake for their own populations and for everybody in the country. Its important to note that while these are tremendous organizations that are investing a great deal in experimentation and learning they are not typical of american employers. Any small and medium sized employees around the country to influence health care. I think one thing well talk about is the implications for these kinds of strategies for other employers who have the same resources to effect the market. We think theres a lot to be learned. What i want to do is take a minute to transition between the first panel and the second and mention a few of the themes i think we have heard. We talk about implications for the market as a whole. First there are lessons. Most of the topics you have heard described today have a mirror image. So we do want to be learning and have a dialogue between thought leaders and people here who are developing much broader Public Policy statements. What the employers seem to have learned is they have to be thoughtful in crafting the en e environments which they are crafting. They are engaging in direct discussions. They are not relying only on their health plan as a mediating organization but they are critical as everyone said but they find themselves needing to drive with the providers. Moreover they remain in direct conversation with their provider systems. If you get into the weeds of some of the models you have heard about today youll see how much energy they are putting into understanding the care paths and trying to support them in making necessary changes. Implication of that is something we are thinking about as a group. We all talked about Insurance Coverage and insurance products. What we are hearing is what needs to be done and that means a reallocation of roles for everybody in the system which we have to see more about so the signal to the Provider Community and the public is very important. We need a dialogue between Public Policymakers and private employers about what that is and how it can be reenforced by everybodys behavior and action. I also took away observations. First of all their concerns are the same as we hear in state houses and hear in congress. They are acting on the same concerns, same costs and same variation issues. They are often using same approaches as we mentioned. And make things happen in our economy and of the world. That is first problem solved. Cost solutions will follow quality solutions. We all agreed we will have to measure that quality and design programs and improve that quality in an accountable way. They are deeply invested in understanding their work force, Provider Community and impact of the health care they are arranging on their work force. This is not a superficial engagement. There are some differences, things they can do and dont do that dont apply as much as Public Policy. You heard their work force can be concentrated and can be rural and can be urban. An organization like medicare that they dont have as much ability to tailor and flex. As we think about changes in Health Policy well need to think more about how to allow for appropriate. They have very different case makes. So those are some of the broad things we heard. We will talk about the implications we have seen in the activities of Public Policy development coming forward. Ill invite them to take it from here. We will confuse because we on the part the washington outlook, at least many of us do. With that let me make a few comments not stonding there davids comments were an excellent hand off for this panel but he didnt mention medicaid. There is a tendency, i think i certainly have it, to think about medicare and then sort of, medicaid is kind of tough because the states run this. There is a growing appreciation that the employers we heard from this morning clearly recognized if you dont Pay Attention to the client population, if you dont understand something about the Delivery System in the local area rather than some generalized sense youll probably have trouble implementing cost saving value and changes in policy. So i think its a real possibility that part as further reforms. We are just going to call it by different names and its going to continue on forever, which is, i think good for this panel. If it were not the case we would all have to find other jobs. I think part of the future of Health Care Reform is reader appreciation for the rural states. So i think thats something that we may well see perhaps later this year. Let me introduce the panel. Im going to introduce people in order of speaking. First we have lynn nicoles. Lets see. I have to find me lynn is a distinguished two pro feser for Health Policy research and ethics next we have clay who is principal and is actually a great deal of experience with Prescription Drug business fda regulation and so on. He spent earlier times up on the hill and so he knows where some of the bodies are buried. Then karen fisher, karen is now at the association of american medical colleges. But before that many years working on legislation for the Senate Finance committee and other roles. Fin finally ovick. It is a great new effort called the foundation for research for equal opportunity. It is not just narrowly focused on health issues. Ovick as many of you have seen him on tv is a true Health Policy expert. With that why dont we start with lynn. Well argue with each other until you stop us. Thanks, joe. Joe gave us five minutes. So i will try to make three points. You can use ten. No. No. No. I will stick to five. Thats fair. So i have three points. Two about whats going on now and one i think we need to think about going forward. First i want to begin about how happy i was to hear him say the word bipartisan seven times. Every single paul ryan budget, go back and look at every single one of them, including all of the medicare payment stuff. The most comprehensive produced before the election, he is a longtime collaborator who always wrote the defensible way to think about this right on the hill. Hatch is chairman of finance. That bill includes all of medica medicare. As congressman laid out it passed with just about the largest bipartisan majority since world war ii. That is a very very good start. The second point i want to make is this Public Private cooperation that has been waxing and waning and going on is a twoway street. I think you can see a lot of good features that are coming out of that. First and one of the things i liked best about the way the invasion center did its business was emphasizing multipayer mi h initiatives. The reason it matters is basically to get the incentives and reporting requirements aligned between payers so that they can focus on what they went to medical school or Nursing School for. I know where i now have the pref l privilege of living. They are recording between 240 and 500 different quality different quality me tricks. I dont know what the right number is but it aint 240. I can assure you that. We have got to do a better job. The only way to do that is get that going on. There are lessons that i think you can learn from some of the different similar but differently structured activities. It is the core of making it work. It is the core of making our Health Care System more patient centered. Thats the idea. Its been tested in lots of different ways. One of the largest public tests was the comprehensive primary care initiative. I dont recommend you read it in one day but i recommend you take a look at it. It basically found, drum roll, no cost savings. The only part in the country that saved serious money was oklahoma. Oklahoma has a really well functioning and Health Department information which takes data and combines all of the pairs and all of the ehrs. They did better. Saved money in year one but not in year two and three. It did not overcome the cost associated with the rather i would even say very demanding requirements of the government in all of the things they wanted the primary care docs to do. Contrast that with the patients private sector i know a fair bit about it because i have been evaluating it. It is maryland, d. C. And northern virginia. Unlike the government approach they didnt dictate a whole bunch of things. They wanted you to do 24 7 access, same day appointment. Pay attention and focus on care plans agreed to by the nurse manager and the patient, sign the contract then go forth and prosper by focusing on those people. They saved about 2. 8 or maybe 3 in years two and three. The larger point is this, kind of like what i heard our employers say. They dont really want to get into the micro managing business of how to do it but they want to set the right financial incentives so the docs can do it. Maybe an important lesson is instead of getting a bunch of experts in a room and saying this is what we think doc should be doing, maybe what we should be doing is focusing on which patients to focus on. That is a very very very important thing. The evidence is the date that predicts which [ inaudible question ] [ inaudible ]. The secret of health care which is surprising. That is market power on the part of survivors. As big as walmart is it cant really tell local hospitals what to do. Boeing is in a little bit different place in about three places. You can do it, sort of kind of. So no employer has enough market share to drive it. Its a better way that we know congressman ryan and others will push pretty hard. Okay. Fine. Thats done. Let me point out and read that thing closely. Its all about turning medicare other to health plans, which sounds clean and nice and simple. Here is the thing, they dont have market power either over a whole bunch of hospitals. If you got it out and turned it over and said good luke. I dont have to worry about it because i dont have to worry about it you will care pretty qui quickly but we need all of the buyers to be focused on exactly how to move to the promise land. Lets talk about the promise land. One really great feature of being tenured is you have time to read stuff that you wouldnt have time to do if you werent. I will tell you three things you should read too, but not in one day. The Inspector General of hhs, you may think what do they have to do with anything . They do sort of evaluations from their own legal point of view of implementation. They just released a report of implementation of Quality Payment Program which is a big part. It is about the physician reporting stuff. You will see pretty clear recommendation for back office i. T. , which is sort of, you know, euphemistic speech for figuring out how to get the data out in such a way that we can actually do what we said we were trying to do in the regulation which you heard congressmans praise. Okay. Thats point one. Point two, read that third year evaluation and you will see even where we are spending 18 bucks for three years you have got places in this country where the docs cant get out what everybody agrees should be measured. And the third little piece is a project that im involved in which is funded by the basic idea to try to enable small practices around the country to be able to help manage patients with heart conditions much better for all of the usual reasons. I signed on and i was told by the pi of the project, dont worry. You just need to work on the statistics. Oh my. I have had to learn way more than i ever wanted to know about getting data out and about the fundamental inability to function the way they were promised. So now i will bring you back. What we are doing in this regulation is we are saying 90 of what youre going to be judged on in the first year comes from either your ehr. 10 of it comes from claims which medicare will tell you what your total cost is. I submit the you those percentages should be first. We should figure out how to get the data out. They should not be required to have to produce these on their own. We dont want them to learn. We want to enable them to participate in an infrastructure where they can bring two clinical Decision Making all of the data they need in realtime and it can be done because oklahoma proved it can be done. We need to think about how to build that i. T. Backbone so that doctors can actually participate in the 21st century. Let me tell you whats going to happen if we dont. These little practices which are still the core of our nation are not going to be able to compete. They put four to 9 within three years of total medicare revenue at risk and its total zero. Youll lose if youre at the bottom of this pile. They cannot win because they cannot make them generate to tell them how to do better. We have to do this for them. It can be done cheaper. It will have to be an infrastructure kind of investment. Ill stop. Thank you. Glenns talk reminds us all that in washington we have a different standard of measurement. So if that was five minutes, well [ laughter ] bill clinton time. [ laughter ] clay, take it away. First i want to say thank you so much for the opportunity to be here today and to speak. I want to echo, i learned a ton from all of the speakers this morning. Thank you for those contributions. What i would like to talk about today is the uncertainty here in washington. It has been what we have all been facing since the election and uncertainty about everybody that had a memo and had to rip it up and recalculate on every single issue across the health care landscape. So there were a lot of predictions around that. So what we do in washington really well is ill make predictions. It is why i think they are sound. It is where some of the things that may progress. It will be a very busy year across the Health Care Sector here in washington. Everybody will be implicated in the discussion. One thing that i think youll find is a bipartisan idea and it will be throughout what happens. What i would like to do is walk you through three different settings. Congress and the private sector about some of the ideas from the first panel, will they present themselves that we are going to have . First we have congress. I think i walked a lot with dr. Burr guess. He did a tremendous job of walking through what you can expect from his committee. Thats where i did my work. They will have a full plate. But the predominant what we are going to hear is about repeal and replace. It will take all of the oxygen out of the room. It will be where all of the activity from the policymaker standpoint is going to be centered. When you look at repeal and replace and i echo that it was definitely welcomed news. I think when you look at repeal and replace one of the questions that gets asked and should be asked is whats involved in that . What are you going to see in this piece of legislation . With repeal and replace and what republicans have been talking about since the passage of the Affordable Care act is a need to reduce costs for consumers. It has been one of the main arguments. You have your policy debate. It is reducing cost for consumers. It will be a focal point that they want to put forward to try to accomplish that. So the better way that dr. Burr g burrgess talked about, they both have one key component and that is Health Savings accounts. Health savings accounts is something the republicans have been talking about for a long time in policy circles. And i think that is an idea you heard a lot about really well in the first panel. What they are going to look to do is find ways to foster the continued expansion and continued you know, make it easier for folks for veterans or others to continue with Health Savings accounts. So that will be one important feature. A second part of it and youre going to hear a lot about repeal and replace and whats going to be in repeal and replace. I think joe said it really well that a lot of focus has been about medicare. Obviously medicaid has a big part of that as well. I think what youll see in repeal and replace is there will be a lot on what can happen to make that work and what can happen to consumers. There will be a lot of talk about medicaid and what the future of medicaid will be and how that will move forward. Medicare, it will be part of the debate as part of repeal and replace. Its not likely to be a prominent feature. It is not a big part of it. It is what you have heard from senator alexander. It is as much as it is a huge issue on the republican side. It wont be part of it. It will be part of the congressional debate though. What i would say is fiscal year 2018 budget, right now it is around the 2017 budget. Thats what is going to give the reconciliation to begin that process of repeal and replace. There is actually a vote that will happen today that will approve the reconciliation instructions and that process will basically start. So phase 2 will start. It is a little odd to pass the budget after youre already in the period. Youre already spending the money but its not necessary to move the reconciliation for republicans. For fiscal year 2018 i talk about the policy debate. There is going to be a real sense among the republicans in congress and from the administration to try to find some fiscal order that around spending that were part of it the why that budget wasnt passed and in this budget as you look at it what we are seeing from the federal standpoint is that mandatory programs are crowding out discretionary programs. So when you look at the caps that are a part of the federal standpoint the discretionary caps, whether its the Defense Department or its for how much you know, for health care or how much more money there will be for nih, all of this is centered. The issue that has been here and will continue to be a problem according to the republicans unless it is solved is that the mandatory programs, medicare and medicaid are crowding out the rest of the bujd and there needs to be some kind of, you know, order brought to that in order for the federal budget to actually work. That will be part of repeal and replace. You can see substantive changes that you need to take into i count. On the medicare side these budgets are very important for policy debates and for setting the caps. They are not going to change substantive law. They are not going to see it is not going to be part of law. It doesnt have anything that would directly effect stake holders. It is something to caution and to qualify. But that will be where the congressional debate will center and something they keep into account. The move to value, the need to reduce cost, to improve quality will be something that will be talked about. So those topics of the first phase will be part of that as well. Now, where will the debate related to value continue or policy questions continue . The executive branch is definitely something that is front and center that we need to contemplate and think about. So with respect to that, while some and republicans would want to move forward with medicare reform its not likely to happen because theres enough on the plate and theres a political sense they cant take down on as well, that said on the executive branch may present opportunities for them to test certain ideas and continue to test certain ideas that are already started whether it is the bundle payment and others. Thats where the question will come for dr. Price and for others that are situated there as to what they want to do and how they want to move forward. So with that and i think the relationship with how it will move forward, the past year you have seen a basically the name recognition and the understanding of cmmi has changed dramatically from a congressional standpoint. Whielt was doing a lot of work and moving forward a great deal there wasnt a lot of focus except for dr. Burgess and others. So that is a place where the name recognition has gone higher and created concerns for what its future is. You know, its my thought and ill walk through why is that cmmi will play a large role in a new administration. It is for several factors. The first is macra. Karen and i had an opportunity to work on it when we were on the hill and see it get enacted. It is a key factor here in that both sides of the aisle want to see it succeed. Both parts want to be right here. They will take steps whether its working together on letters to cms or others to ensure it works. So they will want to make sure cms continues with hes going to have hearings at his subxwhicommittee. There will be hearings at other places to make sure macra continues. But for macra to continue and for one of the key components of the Quality Payment Program, right, its mips and its advanced apms. For the advanced apms to work you need the programs, you need the models from cnmi. S so you need those there so you can qualify for the bonus payments. Changes that will be seen if there are any kind of changes to those programs or a discontinuation, thats going to cause a lot of problems not only with its going to cause a lost of problems with stakeholders, with clinicians across the country who view that as a very attractive place for that to be. Why . Theyre not going to get the negative adjustments. They can continue the investment and the move to value. And they can move to a place where quality is important and they can move to a place how they want to practice. That is one place as the executive branch as dr. Price and others take their positions theyre going to have to consider. The second piece to this whole and this is something that congress will have to deal with and as well as the executive branch, is that cbo, the congressional budget office, believes the cnmi is going to save the fiscal the federal government a great deal muof money. Id point you to the testimony in front of the House Budget Committee in september where they testified in that testimony they outline and really lay out why they think its going to happen. Its around the process. Its around the process that cnmi utilizes to put forward these demonstration programs. And they believe that process is a really good process. Its not necessarily what has been picked thus far. Its around the process thats been utilized to move forward these quickly and to get them out to test to see if they actually work or not. Under cbos estimation, the next ten years, theyre going to save 34 billion under cnmi and in the out years probably a great deal more. So thats something that the executive branch and congress will have to consider as well. And the final piece to this and i think an important piece is because theres not going to be a substantial medicare reform likely this congress the question is where do those ideas come forward . How can republicans move and look at conservative ideas in medicare and how can they test their own ideas . Well, you have the apparatus already set up. So thats where you could see different whether its a premium support model or other models being put forward under the executive branch. You can see that in medicare. You can see it in medicaid. Also chip. Theres other ways to test this out. When its your power, when its your ability to its your car to drive, that makes it a little less likely you that want to get rid of it. Thats just something to consider as well. And then finally ill just move quickly to the private sector. I think with republicans and democrats as well they want to hear about whats happening in the private sector. They want to hear about the Success Stories that we heard about on the first panel, and that private sector leadership and that data that they can share are incredibly persuasive and incredibly important for them to be aware of as theyre moving forward. And one opportunity i think is there is around with cnmi and with some of the executive authority they have the ability because theyre operating these Public Programs and because of whats in the aca to actually waive certain requirements. They can waive certain whether its a kickback statue or stark or other pieces that may make these models or demonstrations harder to implement. And so as you look at these private Sector Opportunities and i think the bipartisan belief that this how can they foster, it theyll be looking to that. Thats one question i would pose. And a note that was asked earlier too by the audience is what can be done to basically foster an environment to move these forward in the private sector and what can be done to reduce those burdens. This is something that congress has already indicated that theyre interested in. I know with karens former committee, Senate Finance, there was a white paper that was released by chairman hatch. There was a hearing that was held. Were there asking these very questions. And i think thats an opportunity for folks outside of these Public Programs to move forward, to continue to though shah leadership, to continue to show that innovation so the Health System can move forward in a good way. Okay. Thanks. Dr. Burgess raised a couple of questions which probably good thing he didnt answer them. His questions were does policy drive innovation or does innovation drive policy or does innovation occur in spite of policy or independent of policy . I think thats probably the better way to think about it. There are an awful lot of people who seem to think that all great ideas stem from the expert minds in washington who are insulated from much of the real world. And i think thats a real problem when it comes to setting policy because in the end federal policy will drive an awful lot of what goes on. The first panel, at least one of the speakers, several speakers i think pointed out that theres a tendency for washington policy to want things to be uniform across at least the Medicare Program. Theres pressure to be uniform in the medicaid program. Thats a real problem. And i think one of the lessons we can take from the private sector is that uniformity doesnt generally work unless accidental accidentally you can find two situations that are fairly similar. With that, karen, take it away. Thanks, landon. Thanks for the invitation today. And im just going to do sort of a litany of items because len did such a good job setting it up and i want to make sure theres time for avik. What we do want uniform is we want highquality care uniformly. Now, how thats done and how thats done in local areas could differ. But i think with the opportunity with telehealth and with the opportunity to spread information quickly theres an opportunity to ensure that we used to think highquality care only happened in certain parts of the country theres an opportunity to make sure through clinical guidelines or other mechanisms that we can get that across the country. I think we would all probably agree on that. I do want to pick a little bit on macra and the idea of bringing in the private sector. As clay mentioned, that this was the physician payment bill that passed several years ago. And for several years prior to that there were a number of hearings done both on the house and the senate side that brought in the private sector. Employers, physicians, providers, health plans. And said what are you doing, how are you working with your physicians to ensure highquality care in a way that also is fiscally prudent. Sometimes while legislation can take a while to happen that can be a good thing because it allows for that type of discussion to occur. I think thats in part the reason why that bill was so bipartisan and had a lot of support by the Physician Community and the Provider Community and others, was because they were so much a part of it. And i think thats important. Let me point to another example of that happening more recently, and thats an effort on the senate side by there in the Senate Finance committee thats been working on a chronic care bill. Particularly for the Medicare Program. The chronically ill are the most expensive segment of that population. And trying to get a handle on making sure those individuals have highquality care and in a way that can also look at the cost of that is very important. So senators hatch andwiden and senators warner and isaacson came together and led the finance committee and had again a lot of discussions with outside groups about what they were doing with the chronically ill and put together the white paper and introduced legislation at the end of last year, Bipartisan Legislation that was introduced at ways to improve the care that the chronically ill receive. And i think thats going to be an effort thats going to continue because while there can be disagreements on one issue oftentimes as clay and i and others know theres discussions going on where people agree on other issues. And i think chronic care is one of those areas that we should watch out for. The panel before talked about quality and the need for quality measures. I was pleased that in the physician macro legislation there was money put in there, 15 million a year for five years, for Measure Development. Quality Measure Development is not a big money maker for private industry because the measures have to be public and cant be proprietary. Identifying, and as was mentioned before, getting good Outcome Measures and getting those measures so we dont need hundreds of them but can get to be a subset that really identifies highquality care is really important and i would argue thats almost a governmental role of saying look, Quality Matters to everyone in this country and government has a responsibility to help fund those measures rather than put them on physician groups or provider groups et cetera. Len mentioned quality alignment. I think theres a role for the government to work with the med sxair Medicaid Programs along with the private sector. And some of those efforts are ongoing right now with voluntary efforts that are occurring between the medicare agencies and some of the other health plans. But i think everyone would agree. And certainly when clay and i were on the hill we took lots of meetings where that was exactly the case, the providers came in and said how am i expected to do this where i have different payers and yet im being expected to do all of these different quality measures . And in the midst of Everything Else thats happening right now len mentioned about the health i. T. Area. And in 2008 or 9 the government did put funding into encouraging, incentivizing providers to implement more Health Information technology. The good news is lots of people took them up on that and hospitals took some of the money and worked on information technology, they put a lot more money of their own in and physicians go into it. You go into a lot of physicians offices, hospitals, and you see computers. The issue is now translating that technology into new information and how do you actually utilize that as they gather information to actually improve care. And i think that this administration as we look forward has to continue to build upon that and see how we can utilize the publicprivate sector role to take Health Information as len mentioned and make it not Just Technology but into information. And to build upon that it is the data piece in getting feedback data. And macra, i think part of the reason people view it so favorably is because it tried to address many of these issues. Macra has information in there talking about from the medicare perspective making sure the medicare agencies give feedback data to physicians so that physicians can see whats going on, not only for themselves, what theyre doing, but when their patient gets into a hospital. What about postacute care . Whats going on with their patients . Its by far not perfect. I would say one of the issues is that the government and the medicare agencies dont have probably the systems they really need in place to efficiently turn it around. But theres recognition that needs to be done and in the midst of Everything Else thats being done these are areas that probably need to be looked at. When we look at value the other thing weve been seeing as these alternative payment models and valuebased purchasing and readmission programs have been taking place is were learning more. And what were starting to see is the socioeconomic status makes a difference with providers. And while providers have a certain role and can do certain things, sometimes socioeconomic conditions of their patients, the environments and where their patients live, whether they have a Family Caregiver around them, whether they have transportation, whether they have good nutritious care around them affects how much health care they need. So as we start to look at policies, we need to look at issues that we hadnt looked at before. Things like socioeconomic status, things like more risk adjustment, et cetera. And then finally i think on my list is that when we talk about the private sector we probably do need to look at the antikickback rules that were set up in a different area, set up in a fee for service area where we were trying to say oh, if anyone talks to anyone else theyre trying to influence them to get a kickback for the care. And were in a different world now where were trying to encourage collaboration, encourage coordination, and thats an important law that needs to get done. Ill just finish up with saying one thing. I was asked to be here for the most part because because of my background working with the Senate Finance committee. Im now the chief and ill take 30 seconds with the podium to say as when i hear about the private sector and look at reference pricing and looking at giving more transparency about the price of providers, as we do that, again, we cannot look at those issues in a silo. We have to look across the board in terms of all the health care that occurs. If you look at the major Academic Medical Centers in this country theyre a subset of the population but they do all of the physician education and that costs money. They are the places where theres standby capacity and where if theres a next ebola crisis occurring they have to be ready to be able to do that. That costs money. And historically, medicare has paid a share of those costs. Not all of them. And to be honest the private sector through negotiated rates probably has picked up some of that. To the extent were going to get more transparency about how much it costs to provide care were going to have to have an honest discussion about how those other costs that benefit echl r everyone are going to be taken care of. I encourage us as we think from a policy standpoint that we have to look across the board on all of those issues. That should be easy to handle. You know, theres some irony. I dont want to admit how old i am either but i do remember in the early stages of my career back in the dark ages that we were talking about care coordination. And that was the same era the antikickback rules were put in. Which clearly meant that once again washington policy makers did not understand that things are connected. And thats i think one of our biggest problems. We dont understand the connections. Ing and of course its many of these things are hard to see until you do something. And then realize that you may have a problem. And then the issue is are we able to then admit that it doesnt work anymore . I think thats going to be a real challenge for the foreseeable future. Avik, please take it away. Thanks, joe. Its great to be here with all of you. Maybe what ill trying to do is draw from that earlier panel i had with the Large Employers because i think part of our task here was to say what lessons can the Public Policy Community Learn from what Large Employers are doing . And then step back and talk more about the broader context of my views at least my two bits on what conservatives and republicans in congress should do on Health Reform more broadly. Im going to talk about three things that i drew from the Large Employer discussion. The first is the discussion of accountbased reimbursement. Health savings accounts. Health reimbursements, et cetera. Eli ziad at wells fargo did a good job of showing how they are seeing an uptick in utilization quality from hnas and hsas. And i think one of the most promising aspects of the new reform environment were in is i hope we can broaden the utilization of those lessons. Broadly speaking, weve been living in this era for about 50 years now where the central dogma of Health Care Economics was handed to us on stone tablets by ken arrow at stanford, who said that the laws of economics were magically suspended when you talked about health care. And i think what Large Employers are relearning on our behalf is that the laws of economics are not magically suspended when we talk about health care. Laws of economics apply to every good and service thats trance mitted in the economy. And if you give patients more control over the Health Care Dollars that are being spent on their behalf, well, voila, you have a more patientcentered Health Care System. That shouldnt be surprising because thats how the rest of the economy works. But sometimes we struggle to appreciate these basic lessons in health care. So thats point number one, that more agency for patients, for consumers is better. The second point id make that i draw from the discussion was the value of longerterm relationships between payers and patients. This was a missed opportunity with the aca where theres an Enrollment Period every year, which means that if youre the Insurance Company enrolling that patient for a year a lot of the longterm Preventive Health outcomes type work you that might want to do, youre not sure youre going to capture the value of that work down the road. So we heard from dr. Burgess about the high price of hepatitis c drugs and why we should pay whatever gilead wants to charge because theyre cured of hepatitis c maybe down the road. That Insurance Company doesnt necessarily capture the value from that. Because 20 years down the road theyre on a different Insurance Plan or maybe theyre on medicare or whatever it is. One thing we can learn from switzerland and reggie hertzling from Harvard Business school talked about, this, if you have a fiveyear insurance contract rather than a oneyear insurance contract, for example, then an insurer has a lot more ability to say i invest in prevention, pharmaceutical compliance with cardiovascul cardiovascular, metabolic, though kinds of issues. Im going to yield those savings down the road and that can translate to lower premiums for that enrolle. The more we can move the longerterm relationships between payers and patients and have insurance contracts that reflect that i think thats going to be a significant value driver that a lot of us arent talking about in the policy world. The third thing im going to mention is price. Ube reinhart and a number of colleagues in Health Affairs i want to say this is 20 years ago now wrote a great piece for Health Affairs called its the price of stupid. And the his point was we all talk about utilization and say weve got to reform delivery and tweek tweak this and tweak that so people dont go to the hospital 20 times for this instead of 19. Thats all great and we should do that very hard blocking and tackling and plumbing work. One thing we should understand is we all complain about the high cost of u. S. Health care. But utilization is not the driver of the high cost of u. S. Health care. To take one common metric of health care utilization, which is an average length of stay in a hospital, were actually one to two days below the oecd average for an average length of stay in a hospital. Were much better actually than our typical european or canadian or australian peers in getting people out of the hospital. So were already doing a lot of good stuff. The problem is the average day in the hospital in the United States costs five times as much as the average day in a hospital somewhere else. And thats not because were doing five times as much stuff. Its because the mri costs six times as much. Its because the drugs cost 50 as much. Right . So its the prices that are driving high costs in the United States. Much more than utilization. We should do what we can to make sure were not doing inappropriate care, of course. But if we dont tackle prices were not going to lower costs. So i think that the experiment that calpers did on reference pricing with orthopedics and in other areas as yvette talked about i think is incredibly important because it showed that you have a lot of providers saying we have to charge 40,000 for a knee replacement, thats our underlying cost. You cant make us do less than that. Well go broke, well close. Then when calpers came and said sorry were not going to pay you 40,000, were going to pay x and if you dont pay x the patient will go smerlas, magically all the providers said thats a great price, well take that, thats awesome. Theres an enormous amount of fat in the system based on the prices that people are charging. And this distortion was created by the employer tax solution of world war ii and the medicare system that came about in 1965. So the more we can move away from that and give payers more flexibility and latitude in price, particularly with reference pricing, i think thats extremely important. I also want to thank joe because yvette and i were classmates in high school in michigan in the detroit area 30 years ago so youve given me the opportunity to run into her after all this time. Oh, my goodness. Which i appreciate. Shes probably going to kill me now for dating her. Now lets draw back and say what does this mean for the Health Reform environment. I want to double down on something that i think alice riv lichlt n talked about and dr. Burgess talked about and that is the importance of bipartisanship in the health discussion. Im personally very concerned that a lot of republicans while theyve criticized the aca for being passed on a Party Line Vote are either resigned or eager to doing the same thing in reverse, doing everything through reconciliation where it only takes 50 to 51 senators as opposed to trying to come up with a durable Health Reform that has 60 the support of at least 60 senators. I think that can be done. To give my think tank a plug, the Health Reform plan weve published at the foundation for research on equal opportunity, which you can get at freeop. Org. Freeopp. Org, it was built from the ground up to achieve the objectives of both democrats and republicans. Its designed to cover more people than the aca, improve Health Care Outcomes for the poor by reforming medicaid, but also reduce spending, taxation, regulations and costs by utilizing some of the techniques that weve talked about. I mean, i think that it doesnt have to be exactly like that but that general set of principles lets try to achieve the democratic principles of coverage expansion and marry those to republican objectives of Less Government and more cost control. That can be done. And the aca didnt get that done to the degree certainly that a lot of us wanted it to be done and i want to encourage remembers to do that. I think thats how youre going to get to 60 votes for any robust replacement of the aca. And if we dont do it then the result of this new environment for Health Reform is not going to be satisfactory to anyone because what youre only going to be able to do is take the tax credits or the dollars the aca was spending and maybe spend them in a slightly different way but unless you can change the regulations and other key elements of the aca that are not subject to the Senate Reconciliation process youre not going get to a more marketoriented and consumerdriven patient Health Care System. Thank you, avik. Thats a great way to end the formal remarks because it leaves one with a sense of despair. One of the big issues of course is how do you make that straddle from a system that in many ways hasnt worked to a system that might work . And i think thats going to be one of the big challenges for not just republicans but for democrats. And even more importantly for the Health Sector and for patients and consumers. Theres a lot of talk, especially in the press, that this is somehow just a political issue. And thats prong. It is true that a lot of middleclass people have no idea how the aca may or may not have affected them. They have no clue whatsoever about that. But they also dont foe what they pay in premiums generally either. That doesnt mean they arent being affected. And as we go along i think were going to see both because of the pressure for a kind of Price Transparency that probably isnt useful but also the reality that employers, which is where most people get their health insurance, employers wont be able to conceal the fact that theyre taking the money out of wage raises and putting them into the Health Sector. So i think were going to see some problem there no matter what washington does over the next year or two. Well, there are so many issues here that i can personally take issue with. But why dont we see if other people have complaints to make before i start ranting and raving. Since i talked about reference pricing and karen did as well, let me make one point about this whole issue, how Reference Price affects Academic Medical Centers. I appreciate i went to medical school. I appreciate that 34kd schools and tertiary reform centers have costs that are different from a community hospital. It doesnt seem to me that the right way to subsidize that is to make everybody pay more for their health insurance. Maybe the right way to pay for that is to have direct subsidies that go to Academic Medical Centers, clean that up instead of advocating for a status quo that isnt serving anybody very well. I think thats a conversation worth having. You need with these type of systems to have the stability over time. So the direct subsidy would have to be stable over time. But i think its a discussion worth having. I dont want to turn that into that type of discussion. I appreciate that, avik. Let me just add, too, and just throw into the equation that we talked about valuebased purchasing and alternative payment models. We have seen over the last five years, six years now, that there has been a slowing in the growth of health care spending. And some people say is it the recession . Is it really a change in how were providing health care . Or weve seen it in the Medicare Program and those people for the most part are retired. So its not saying were going to hold back on our care. I think weve seen some positive signs about the ability of providers to come together and actually try to work on bending the actual cost curve. Because what i worry about is sometimes the easy decision for the federal government is to shift the cost, reduce the federal Government Spending curve, but the costs move over to the states or move over to beneficiaries. If we can actually get providers to Work Together and look at ideas that actually bend the Health Care Cost growth, Everybody Wins under that. The federal government wins. States win. Beneficiaries win. Wait a minute. Somebody loses. Bend the cost curve means spend less money, right . Do i have that wrong . So if you spend less money, then that means that hospitals will get paid less. Doctors will get paid less. Not necessarily. If you cut out the middle sxhan reduce the compliance wait a minute. This isnt economics. This is accounting. No, not at all. Because what if hospitals and physicians spending a lot of money on . Its not merely revenues. Its also costs, right . Income is revenues minus costs minus taxes. So if youre spending if you get it and if youre billing for a lot but youre also spending a lot on compliance and regulatory costs and other things then your actual income is lower. So yes, you can spend less money, but if you actually streamline the system so that the costs of delivering care to patients in terms of regulatory compliance, middle men, accounting, billing, compliance, if you can reduce those costs you can actually end up with more savings in the end and actually a system that stakeholders appreciate more than the system they have today. Well, certainly if you could reduce administrative costs to that extent id agree with you. The issue goes back to will we ever really divorce ourselves from fee for Service Payment . Basically, all Payment Systems have a fee for service base because you have to start somewhere. And so im a big fan of capitation. But the big hmos dont like to talk about how they pay their individual practitioners. But its highly likely that theres a volume basis at least in part. Theres some kind of Performance Program that isnt just value based. And a salary component. A base for practitioners. Its not at all clear how this miracle will occur. Joe. Joe. Theres plenty of ways you can get to the miracle. But lets be clear. I agree with you that were not if we didnt have fee for service wed have to invent it. We have to account for whats going on. But you can do that without having 1,500 different payers have very different ways of paying for roughly the same cpt codes and roughly the same icb9s. Im back to alignment. Thats my magical thinking for the day. What if we agreed that all the payers would have the same set of Quality Metrics by which theyre going to judge the individual providers . Yes, you can pay Different Levels and yes, you might have different forms of incentives or rewards, but as long as the metrics are the same and as long as the provider has applicable incentives that are the same across all payers then you can get to nontrivial efficiencies. Ill also remind everybody of the thing called claims adjustment algorithms. A lot of that billing stuff that docs spend their money on, what is, it 20 cents for a hospital to get paid, 20 cents on the dollar for a hospital to get prayed. 35 cents on the dollar to get paid. Thats all about having all these different payers with different rules about getting a claim accepted. What if we had standardized ways to do that . And you know damn well we do. We just dont have the courage to enforce those standards that i way that would achieve the first,s th efficiencies that avik is talking about. It is achievable. We just have to have a more targeted curve. You dont have to have one size fits all uniform standards if technologists can play a role in being the interface on the Decision Support tools for providers and payers and the like. And that is restricted by antikickback laws, by problems with data liquidity, hipaa, et cetera. So thats a whole area of work where its not very sexy but we need to spend more time so the Athena Health and whoever else we want to put in that bucket can do the work, serners, et cetera. Epix, to be able to create a system where everyone can Work Together. And theyll take those costs out of the system. Lets be clear. We dont want to turn this over to epic and serner and say good luck. Of course not. The fundamental problem is no ones focused on getting the clinician all the data they need to make the decisions they need to make both clinically and financially. But theyre legally barred by doing that. Because there are certain types of information that if serner or epic or athena tries to deliver theyre actually barred by antikickback laws from doing p t. Im totally in favor of fixing stark but that aint the biggest problem. The biggest problem is somehow, and we can talk about how if theres enough liquor in this building, but somehow the hr vendors got to be owners of the data. Thats wrong. Sure. Docs and patients should own the data. Period. Done. Were done with this. Weve got to fix, that then we can fix Everything Else. Economists call it externalities. When you talked about the fee for service basis, thats always the structure, i think when you look at macra, thats a representation of trying move away from it when you look at the Quality Payment Program. Man, thats really great. No, just meaning that with mips thats where everybody is situated now and were trying to move into the alternative payment models. But thats where the ideas from this mornings panel are trying to be represented in private programs and the publicprivate alignment. Okay. We dont want goat into an tensive discussion of alternative pay models. Well get some questions from the floor. And that has to do with i think a very fundamental issue that several people here alluded to, which is the shortterm view that Health Financing and Health Policy takes basically on everything. Its somewhat ironic. The Medicare Program ought to take a longterm view because with the baby boomers theyre stuck with them for 20 years or more. And yet most of the policy is oriented to one year. And if there is broad thinking, its that tenyear cbo score, but where it really matters is year by year. So thats a problem. It wasnt emphasized in the employer panel. But you would think that the Large Employers would have a longerterm viewpoint. But i think theyre trapped in the mechanics of short oneyear contracts with health insurers. Clearly the big employers recognize that their workforce, at least the highly skilled part of their workforce they want to hold on to. So thats also a longerterm relationship. And yet all of the relationships have been to date really more focused on the short term than the long term because its so hard to capture what was the result of whatever you did up front as a health investment. How did that really affect health and how did that affect cost even past the first year . Its really hard to know. I just wanted to make that observation. As something we all need to work on. Thats why i made the point about longterm insurance contracts. Right, right. Exactly. And avik i think a lot of people have been thinking about longterm insurance contracts for a long time. And the reason we dont have them is because insurers dont want them. Lets be clear about that. But lets think a little bit about what the deal is. Insurers want the freedom to observe, ooh, you turned out to be sicker than i thought. And Patients Want the freedom to observe i dont like the way theyre treating me. So we do have a tension between the absolute efficiencies of longerterm commitments and the reality of both choice and protection from risk. Joe, id also say lets remember the providers, god bless them, are just larning how to do risk. Weve been paying them weve been overpaying them for fee for service for quite some time. Because price is the thing. Weve been overpaying for quite some time. Im not sure im going to be pessimistic about the fact that the providers in the boeing world dont want to go to a multiyear risk contract. Im happy theyre doing oneyear risk and theyre actually hitting their targets if i heard you correctly. So i think we should should acknowledge the good stuff thats going on. Absolutely. The only question is how many decades into the future. And i think part of that does have to do with government policy. And medicare, other people have said, medicares a big payer. If medicare doesnt push against its own comfort levels, which are far closer to the body than i think any employers are willing to take chances because theres money at stake. Lets talk about bearing risk and why medicares focus is so short. You know as well as i do it is because of the people we elect and the fact that they have to worry kind of a lot about getting elected kind of quickly. If youre a twoyear congressman you cant be talking about a 20year medicare horizon. Youve got to be talking about what do i do today. You go back to this chronic care model, which thats incredibly longterm thinking. Its actually informed by evidence. What a concept, it can occur from time to time. Youve got to encourage the congressman to think longer term. How do you do that, joe . You tell me. Longterm contract . Im sure theres some kind of a pharmaceutical that can okay. Fine. Longterm contracts arent for everybody. But i think having the option of longterm contracts in a way that federal policy inhibits against them is where medicares moving some of these models is its pushing the risk to the provider or its pushing the risk to the plan. The idea, thats where its trying to do that. Right. And i think you know, having organized health plans really helps. This effort. It can be optimistic about this movement in the m. A. Direction. Those are business organizations that have some size to them. You know, speaking of learning while youre doing, think about how Medicare Advantage today in my view is much stronger than it was 20 years ago precisely because so Many Americans have had experience with managed plans and it turns out managed care is actually a good thing in lots of ways and so were more able to well, you know what . Thats going to be true across the board in these private sector initiatives on teaching consumers how to be smarter consumers. Right. My mother was not a smart consumer. I loved her very much. She died in 2004. She did exactly whatever her primary care doc told her to do. Right . Whatever. What do you think, doc . But my child does not think that way. And so fundamentally its about learning behavior that can help us be better consumers. With that i agree. With that are there questions for the audience . Let me see. Raise your hand. Theres a lady here. Thank you. Meg mcginty with the National Quality forum. Len and karen you both mentioned the issue of alignment. But im sure you know how wed people are to quality issues, how your shoes are good but my shoes are better mentality. How do we overcome this challenge . What are your ideas and thoughts to well, thats your job. Were trying but we got some pu pushback here. I would encourage the following historical metaphor. Constantine when he took over the empire had a problem. And the problem was christianity, which he decided to make the religion of the empire, was split between these who thought jesus was a man and those who thought jesus was a god. So he convened the learned bishops at nycea. Thats why its called the nycene creed. And he said i dont really care if jesus is god or man but youre not leaving till you decide. What happened . Turns out he solved the problem. But my point is youve got to have a deadline, youve got to have a swoerd, and youve got to have a very clear instruction. And in my opinion just for what its worth you could get the relevant players in a room whos the you . Probably aqf has to do it or some okay, you want cms to do it . Cms cant dictate it. But the cms sword might be you awl got six months. I dont really care but if you dont agree were going to do it our way. I guarantee you they will Pay Attention to getting to fixed. But youve got to have the sword and the deadline. Just a suggestion. One of the things that has bothered me about this concern about hundreds of measures on the one hand everybodys right about that, thats too many measures if you expect everybody to report on them. But one of the issues is that some measures are actually appropriate and some circumstanc circumstances. So its a much more complicated world as you well know thafrn i think is often portrayed. Its really difficult. And we spent you out there without the sword. And were very grateful. Seriously. For what you do. But you cant really make them do it on time unless youve got the sword. So youve got to combine the sword. But you dont want cms dictating before the private sector has a chance to work it out. In my view if you do that a lot of examples in history would suggest thats a feasible alternative. Next question. Theres somebody back there. Great. Good morning. My name is Jean Drummond with health care dynamics international. This has been an amazing panel. Thank you so much. One of the questions that i want to ask, we have the opportunity of working across the country trying to dot transformation of clinical practices because of macra. And were clearly seeing the challenges with the small rural practices. Clearly the data. Youre exactly right. They just cannot get the data. Theyre almost held hostage by their own data. My question and i appreciate your comment really around the social determinance because many of these clinicians are kind of trapped whether theyre in rural areas or urban areas. Theyre trapped by the challenges their patients many comorbid diseases and the challenge health cares far more than health. And so my question to you is what are some solutions that u. S. Policy makers in analyzing this around this ehr, thats one of the Biggest Barriers that across the system but particularly with the small rural docs are facing. So thats one question around ehr. How do we get through this debacle around interoperability and all of that. Thats one. Two is what are some of your thoughts around risk adjusted payments. Because clearly as we move through acos, you know, theres the option of cherrypicking. Dont like to say that. But thats ultimately how do we manage those. So those two big issues, ehr and risk adjusted payments, particularly with a focus on the small rural docs. Thank you. Id love to make not a macra point but a macro point. Which is you know, when i left my hotel this morning to come over to aai there was a copy of the wall street journal in front of my hotel room door. Because the hotel had in their data base that i like having the wall street journal in the morning when i check into that particular hotel. There needed to be no meaningful use regulation from the federal government to require my hotel to deliver the wall street journal to my door and my hotel room. They did it because they had an economic incentive to provide highquality service to me so that i would keep going to that hotel. And so the irony of all the stuff we talk about with Electronic Health records is that again, in the rest of the economy, i think its always useful when it comes to health care and intractable issues in health care especially, is how does the rest of the economy do it . In the rest of the economy there needs to be no regulations around mandating people to use digital data because its in the economic incentives of the suppliers of services and goods to be as digitized as possible, to be as economically efficient, to provide as highquality service as possible. Its only in health care where you have to mandate it because the incentives are so driven away from the patient relative to other sectors of the economy. So the more we can reform the Health Care System broadly so that the patient is in control of the Health Care Dollars i think a lot of the stuff around ehrs and the intractability of getting people to use ehrs, so long as the federal government i dont want to say gets out of the way but at least doesnt actively try to sabotage it will get a lot better. So look at whats happening in the real world, where it is working. Go back to tulsa, oklahoma. Where this engineer undergrand m. D. Professional works at the university figured it out using banking colleagues, not h. I. D. Colleagues, how to extract the data from the individual rural practices, small practices in such a way that the doc doesnt have to do anything. They finish the exam, close the record, the data flow. Ccda if you know what im talking about, treat into the h. I. E. That night. Takes all the patients from that doc, gives them back, a profile. Youve got three diabetics, youve got five with heart conditions, Yada Yada Yada and three of them coming in tomorrow havent been here in two years, whatever, yada, yada, they need the wall street journal, whatever. You walk in and there it is every single day. How do they do that . They do it through software that is eminently achievable. It can be written by my graduate students. But they have essentially penetrated the wall that prevents this from happening in most of the country. Why . Because the vendors were given too much power by the federal rules. I would argue its because some people in congress wouldnt let them impose rules that may be more productive. So here we are. Lets fix it. Its totally fixable and you have to find examples that are working. Youve just got to break those firewalls down. In the 20th century act that was just enacted in december theres a significant amount of work that will be pushed to the office of National Coordinator to work on the interoperability because i agree. I think theres a lot of concern not only around folks around the country but that has been come to washington and they are trying to push for it. I think thats something youll see. The second piece is i agree with avik on the consumer. The consumer is really the key to this. And the more the consumer and i think the a. R. The consumers are demanding this type of information as folks, you know, care for their parents or care for their kids and are dealing with these records issues, i think they are going to be what pushes this forward. But i would say the providers are equally as frustrated. They really want this to work as well. They want to be able to share it. But they want to be able to do it in a way that makes sense. And as we all know its a very complicated a ton of information to share with a lot of privacy concerns around it. So it is somewhat different from what we see in other parts of the economy. But there are solutions. Yeah. Just to address your other point, i think we continue the same on the quality side on risk adjustment. We need to get this more finessed. And as people live longer and were managing chronic illness more carefully, risk adjustments just going to get increasingly important. And increasingly difficult to do. Yeah. Lets see. Another question. Anybody else . Okay. Go ahead. Thanks for your presentation. My names leah. And i think common sense is price and cost is depend on the consumer to say whether how much he want to pay or whether you can afford it. I think thats totally true. You can see that overthecounter drug may be more useful than you go to see a doctor who is not going to give you anything instead maybe refer to another doctor, another hospital, and everything and eventually of course disaster. So i just wonder if the information from all those providers whether pharma or the hospital can give consumers information that treatment, everythings supposed to be maybe in regulation. They are supposed to give the consumer patients or their family. But that is not true. And you have the right to complain but complaints improperly processed. So are we having a really good mechanism to better procedures or complain and have a record of complain result . Resolution . If we can have all those information available, we can see which officials are doing right, which are doing wrong, and which is totally a disservice. So if we can move this direction so we can have the better choice of provider services. We know whether we are really in trouble in terms of health or in terms of financial situation. Thats a really good question. It boils down to getting consumers. We could call them patients. And their families to better understand both their condition wharkts optio , what the options are for treatment, what the options are for providers, what the aftermath of the treatment might be and of course cost. And one of the problems with the transparency push in washington is they want to talk about list prices all the time. When in fact what the average person really wants to know is whats it going to cost me out of poblth . Now, it is true that for a lot of purposes, policy purposes you really do want to also know what the actual transaction price is. But for the average patient they tend to focus on dollars out of pocket even though they are ultimately paying the rest of it we need to address those issues too. Well, there are tools to do everything you asked for which is quite reasonable. I would say the difficulty we have right now the difference between where we want to be and where we are is we put a pretty big burden on the patient to ask all the relevant parties, all the relevant questions about themselves and in some cases its really the laws and regulations that prevent this stuff from flowing as easily as it should. But i would just observe that burden on the person to ask the question is part and parcel of our philosophical attraction to the notions of individualism and individual choice in patient centeredness. So its kind of hard to push it unless the patients ask for it. I will say a lot of ehrs can generate the relevant Clinical Data on a particular patient in that physicians office. But not necessarily every physician youve seen in the last three years and not every e. R. You have been into from some emergency access. We need a system that enablds you to access that every morning or however often you want to go to a doc. Its feasible, its there in technical terms, its not there in legal and administrative terms. Okay. Very good. One more question . Or observation. Thank you all for the panel and discussion. Several of us have alluded to Market Forces in the course of the day and we havent come back to it yet. And this consumerism discussion opens up this issue as well. Whether you all believe, some of you believe individual consumers acting individually will counter the large dominant forces in both consolidated Health Systems and consolidated health plans, which are in fact to aviks point about price setting, or prices, which are driving higher prices in a lot of situations, our employer friends often find themselves victims of prices in the market that they dont have the market power to counteract or to negotiate dun. What do you foresee as the policy options in the networks few years to address the consolidation on price that would bring all u. S. Pricing into more alignment with International Norms . Its a great question. In fact, theres a whole chapter in transcending obamacare, the health plan i alluded to earlier that addresses this issue. Unfortunately a lot of federal policy like the aca, like macra, are facilitating and encouraging consolidation because of all the compliance regulations you can only get to that point with economies of scale. So thats a huge problem. Theres a couple of things you can do to improve hospital improve buyer competition. The first is we can do something at the state level where there are certificate of need laws and other regulation thats prohibit new providers fren terg the system. I think thats important to try to reform. Same goes tore physicianowned hospitals. I understand the antikickback side of not wanting physicianowned hospitals but they are an important element of competition. I think you have to give more money to the ftc and doj to litigate and on an antitrust basis. If united and Continental Airlines want to merge the ftc gets involved and thats i gig National Merger or if comcast and time warner came want to merge. But if the local hospital of the Cleveland Clinic is buying up or its yale new haven owning aum all the hospitals in new england its too small. Its too small for the ftc and doj often to get involved. So i think we need to do more to draw resources to federal agencies to attack that. And i think the last thing, and this is sort of my more out of the box idea, so s. You could conceive of a system in which there was an automatic trigger instead of relying on doj and ftc litigation you could have a situation where where if provider concentration in a certain locality exceeded a threshold of concentration, dmifts like to use this thing called the herpendaul, hershman index, if you suddenly have a is duonly or monopoly level you trigger an all payer Medicare Medicaid regulation. What youre basically doing is saying if you want to stay independent and compete with each other do that, if you think through merging you can have economies of scale and lower costs do that. But if youre only merging to jack up prices on patients and consumers and taxpayers were not going to let you do that. Okay. One of the sishz willingness to pay as well. I think this is where employers play a really critical role. Employers represent their workforces not just in health care but in general in terms of total compensation. And so i think if you were to ask the average employee if we could give you 10 more would you like to spend it on health care, the answer would be no. Almost certainly. So the ability to resist i think is very important. Ultimately the problem were talking about is a problem of good economic times. And we cant complain about good economic times. But the reality is its very easy to say oh, yeah, okay, well pay it because we dont feel enough pressure to push ba back. We may be headed in that direction not from the standpoint of a negative economy but from the standpoint of really the lack of balance or the misbalance between health care and Everything Else. I think may have gotten to the point where we may be at proverbial tipping point, in which case employers really have a job to do. Were counting on you because we in washington would really rather have someone else do the work for us. Can i make one suggestion on the employer front, and that particularly struck me from the multistate employers, multinational employers, find a way to share what you know about price and cost differenttials across this country. Because the deal is medicare dictates price. They dont pay variable prices. Geographic adjusters. But you all pay all of these things. But thats not part of the data base that triggers doj and ftc. Oeconomists discover p by random chance. But you guys know every single day. Figure out a way to share that with the authorities. Got to be a way. Just show up and have breakfast. Okay. Well, good. Lets weve expended our time. Please join me in thanking not only this panel but the entire group of people. [ applause ] on newsmakers House Democratic whip steny hoyer of maryland talks about the future of the Affordable Care act. President elect trumps cabinet choices and how democrats will deal with the republican