Transcripts For CSPAN3 Politics And Public Policy Today 20160429

Untouched by our counterterrorism effort. So in the future just recognize that in order to restore deterrence, were going to have to show capability, capacity, and resolve. Recognize this is an International Arms control agreement and not a very good one although there are some advantages, recognize the advantages as well. But its not a Friendship Treaty, and some people have tried to make it into a Friendship Treaty say its worthless. As a Friendship Treaty it would be worthless but its an arms control agreement that fell short of a lot of hopes but its not completely without some merit. We have allies out there. We have allies who want to rally to our side. I dont forget sitting with the king of jordan one day. We were working on his syrian refugee problem and i have seen refugees all around the world from the Southeast Asia to africa to the dalmatian coast. I have never seen i have been up in the refugee camps. I have never seen refugees as traumatized as those coming out of syria. I was told by our ambassador to work with the king on what we could do to help in those camps to reduce the chance of cholera and that sort of stuff. I had known him for a long time. We were talking just the two of us, we got done and i asked him whats it like to be a king. I have never been a king. Kind of interested in it and dont draw anything from that, by the way, and he said, well, you know, working on this, working on that and he said, by the way, i hear the french and british had to pull out of afghanistan. I said, yes, your majesty, i said domestic political concerns, they couldnt sustain the campaign. He said rest assured, general, there will be a jordanian soldier in afghanistan until the last american soldier comes home. Ladies and gentlemen, you cannot buy allies like that. You cannot buy them. And if were going to want allies to stand by us in our time of trouble, then were going to have to stand by them when they face trouble as well. And when iran says jordan, youre next, we should take them at their word. Dont patronize iran and say they dont really mean that. Yes, in fact, they do mean what they say. My next stop, by the way, that trip was the country that we in Central Command call Little Sparta because they stand by us through thick and thin, desert shield, somalia, dalmatian coast, bosnia, they have always been there. The united arab emirates. I was talking to the crown prince and he said i understand the french and british are pulling out. What are you going to do . I said im going to have to go back to the americans and ask for people to backfill. Were deep in the fight right now. And he said, well, he said, to reduce your demand on the american forces, ill send six more fighters in. Ill send another reinforced special forces company of 150 special forces, well trained, fully kitted out, ready to go, to fight under your command. Again, ladies and gentlemen, you cant find allies like that if you dont stand by them in their difficulties. So they may not be perfect. If were waiting for perfect allies, were going to be awfully alone in this world and from what i have seen in our own country, were not perfect ourselves. Lets figure a way to Work Together. Let at the stop there and open time for questions here. Thank you. [ applause ] thank you very much for that presentation. Im jon alterman, the Senior Vice President in Global Security and the director of the middle east program. I have a few questions before we go to the audience which is already champing at the bit. One question, you talked about irans asymmetric threats in the region, its activities supporting terrorism, supporting hostile states. Was it a mistake to make a Nuclear Agreement and seem to take the focus off the other activities in the region because as you know, many of our gulf allies say the Nuclear Issue isnt our issue. As a former foreign minister in the gulf told me, if somebody already has a gun pointed at your head, it doesnt matter if they have a cannon pointed at your back. Was the whole approach to put so much effort on the Nuclear Program and nonproliferation a mistake for u. S. Interests in the middle east . The short answer is, no, it was not a mistake. In this town we seem to have forgotten the tremendous effort that went into Nuclear Nonproliferation in decades past, and to our im sure its going to be to our regret and especially to our childrens regret we did not maintain that focus. So i think in the case of iran it was not a mistake to engage on the Nuclear Issue even if we were to give it primacy. That i think is debatable, but even there i wouldnt say its a mistake. The mistake would be to implement it in such a way that we appear to take our eye off the other ball. Thats the mistake. And thats a choice. And thats a choice we did not have to make, and so theres a way to balance this in terms of creating more stability in the region. Unfortunately, we probably have not executed in that manner yet. I mean, its still subject to choice every day by our government. About eight years ago a president ial candidate named Hillary Clinton suggested extending a Nuclear Umbrella to gcc allies against iran. Do you think thats something we should consider and if so under what circumstances should we pursue it . You know, its interesting, i work with a gentleman by the name of George Schultz out at hoover, and he calls he walks in every morning that were out there and he calls us younger officers in and only at hoover would i be one of the younger officers. And he talks about what it was like coming home from world war ii as a marine in the pacific and that generation looking around and 50, 60, 70 million dead, economic privation around the world and the greatest generation is called that for a reason. They say were part of this world whether we like it or not, no more going back pulling ballot on the league of nations. They create the United Nations so we can talk. They create Bretton Woods so we dont have Economic Conditions that are going to drive us into depression and war again. Three years after that terrible war against the nazis and the fanatic pacific war, the Marshall Plan is passed, and were actually helping our former foes recover. I mean, could you do that today . I dont know. But most importantly the United States makes what the australian ambassador to washington told me one time here a couple years ago the single most self sacrificial act in the history of the world. And im trying to think what is that . You have to look at it through a nonamericans eyes. He said you could have turned your back on europe after two world wars and said were going with the middle east and asia. Were going with south america. Were done with you guys. Instead, the american president s truman, eisenhower, democrat and republican, and the Congress Working together in a nonpartisan way, say were going to commit 100 million dead americans in a nuclear war to keep western europe safe. Today could we do that again over the middle east . I dont know that we have the political unity in our own country to stand up for Something Like that in the same way. So ill leave the answer to the questions to the audience. Along those lines, the Number One Oil producer in the world now is the United States. Oil producer. There are a number of people who say that allows us to change the way we look at the world, the way we look at the middle east. Do you think theres anything about the way the u. S. Looks to the world, the way the u. S. Thinks about Global Security, is there anything thats changed because our Oil Production has made us into a global oil super power . I would just give three imperatives for us to stay engaged in the middle east. The first one is oil. We may not be tied to middle east oil so much but believe me from washington to new york, San Francisco to miami, our economy is tied to the world. And if the worlds economy was to see the oil coming out of the gulf disrupted, 40 of the globally traded oil of this globally traded commodity we would get a terrible impact, not only on the World Economy but it would immediately impact here at home. So, theres an economic reason to stay engaged out there. Theres also a diplomatic reason and if we want the nations with us on so many other issues we cant ignore them when theyve got serious issues. A third would be security. Are we really so long from 9 11 that weve forgotten what it was like to look over at the pentagon with smoke pouring out of it . Id suggest were not that far removed from it. No nation on its own provides security in this world. No nation in a globalized world, actually ever, but certainly not today can do this on its own. So, if were going to have them stand by us then we are going to try to stop maniacs from attacks us again like on 9 11, then wed better be working with the folks in the region and look out for our own interests, beyond the moral to the strategic again. One last question before i go to the audience. Well get your questions ready. As you know, everybody in washingtons talking about budget constraints. Yeah. Is there anything were doing in the middle east now in the security field that you think we can afford not to do anymore . Youve talked a lot about plussing up. Building relationships. Is there anything we can stop doing that were doing now . You know, worth more than ten battleships or five armored divisions is sense of american political resolve and i think the more resolution we sew, the more unity we show with our allies certainly we have to do some ourselves. Even farm boy or farm girl knows if you want pump water out of a water pump you have to put some priming water in to get an air lock to bring it up. The idea that we can tell others, here, you do all the fighting and we are going to sit back and be up above and give you intelligence, well fly overhead with restrictive rules of engagement and all and you do all the dirty work, probably isnt going to work. So i think that we could probably get more from our allies instead of grudgingly or belatedly doing things that need to be done and being more forthcoming on it and holding constant high level discussions, remember. Any coalition against the kind of enemy we are up against takes two pieces. Its got a political piece and a military. The political is dominant. The military piece is subordinate and hopefully acting in accordance with the political agreement. And right now, i think lacking that kind of political coherence at the top, were having to do some things we probably wouldnt have to do if we could show more firmness and more conviction in what were doing. All the troops on the ground are just a front for what stands behind them. And without a unified congress, a unified american position with our allies that is a much weaker front than it would be with that sort of support. Is there a syria i mean, a way to apply that to the strategy in syria right now . Yes. I think get the Political Coalition put together up front and make clear where we stand on it. Okay. That doesnt mean 100,000 troops for 10 years or doing nothing. It means using strategy and figuring out how to go forward. Thank you. Sir, you, on the right. Thank you very much. And thank you, general, for your remarks. Im john gizzi of news max and news max television. Ill i guess ill point to the elephant in the room. General, you have been mentioned so often very much like your fellow scholar soldier james gavin was a generation ago to run for president either as a republican or as an independent. Have you given any thought to it . And how serious are the rumors about it . No. I havent given any thought to it. How serious are the rumors . Thats i think people like you know that better than i do. Sir . Over here. Just on the in the blue shirt, yeah. Okay. Thank you. Thank you very much, general mattis. Its second time im listening to you. First time that you were at heritage. Im a doctor. Theres a lot of criticism inside usa as well as theres criticism about this nuclear deal, even inside iraq. Inside iran. And could you tell us, what was the compulsion on the parties which would negotiating that they had to come up with a comprehensive deal with so many loopholes and if the deal collapses what happens next . If the deal collapses, what happens next . I think if the deal were to collapse today it would depend on whether or not the economic sanctions could be reinstituted in a compelling manner. The amount of effort that the state department put into those many years ago was extraordinary. Were now at a point where people are clamoring to get into the iranian market. If you were unable to reimpose the economic sanctions, then i think you would be basically on a road to perdition because the lines of effort inside tehran are so contrary to the best interests of israel and the arab states around it that would lead to a collision. And how you would define a collision, whether it would be open war or a much higher level of terrorism, whether it would be economic blockades, as you know, saudi arabia recently said no ship thats made a port of call in the last three ports in iran can carry any saudi oil. So there are a number of things going on right now that might give us a little hint of what would be coming but i think we would be in unchartered territory at that point with probably only bad things to happen. All the way in the back next to the light stand. Mohammed. Would you please tell us something about the military to military relationship with egypt . And do you recommend the resumption of the bright star military exercise . What was the last relations with egypt and would you recommend resumption of the bright star exercise. Yeah. Egypt is a very, very interesting case. One third of the arab peoples live there. It has been an ally. It broke with the soviet union. Its been an ally since. Its fought alongside us in desert storm. Its maintained the security, the suez canal. A vital waterway. You put all this together and israels gone through very tough times and they did have a democratically elected president , morsi. Egypt. Excuse me. Egypt had a democratically elected president morsi. He was basically thrown out i believe by a public impeachment that the military then shouldered him aside. And then president al sisi came in. Obviously, were concerned about any political system has to have a counter weight and whether or not theres a sufficient all allowance for legitimate political dissent. But that said, right now, the only way to support egypts maturation as a country with civil society, with the support the president , we should have bright star reinstituted, perhaps not with tank battles but with counterterrorism type training, that sort of thing. But i think that when a president comes out two years in a row at alazar university calling for revolution in rhetoric in order to reduce the amount of negatives about the muslim religion, i think its time for us to support him and take our own side in this. Im a strong believer that egypt is a critical nation in terms of the future for stability in the middle east. Thank you. Right here on the aisle. Theres an echo up here, you know. General mattis, im colonel moragi. I had the pleasure to serve under you as a command sergeant. And i want to ask you a question, sir. Given what you mentioned about iran and influence and four capitals and given our engagement in iraq, how do you see us walking the rope between supporting the Iraqi Government with the significant iranian influence in lieu of more fighting against isis, sir . Yeah. Its a tough its a very tough situation. When i was once complaining about my job as i did routinely in the last job, as a matter of fact, i once was asked by the Vice President jokingly, you know why you got the job, jim . I said no, mr. Vice president , i wondered. He said because we couldnt find anyone else dumb enough to take it. I was complaining about it one time and a former Prime Minister in europe said, hey, jim, if you cant ride two horses in the circus get out of the middle east circus. Welcome to reality. One of my last visits to iraq i heard the same message from a number of people in the government in the shialed government and it was help us avoid the suffocating embrace of iran. So i think there is a way to work with iraq where we do not decide to just cast iraq off because weve all read about it enough, heard about it enough. Its got enough complexity. Just be done with it. Be done w. In this case what we are doing right now in iraq while it may not be sufficient is on the right path. All the way on the aisle at the end. Yes, maam. Thank you. Sputnik international news. Question about u. S. Presence in the region. You seem to indicate that more of a naval presence would be the way to go to reassure allies. I would just like you to elaborate on that and when you look at increasing a u. S. Presence, whether at sea or on the ground, combined with more u. S. Weapons going to allies in the region, where do you see that heading . Whats the worst possible out come . Let me also address the best possible out come and i can do it with an example. Several years ago, i was reading again all the reports coming out of tehran and calling for mining the gulf. Remember those days . You all remember all that word about the cruz missiles and we can board the ships. They are mostly about mining. I pick up the phone and i called my fleet commander and i said i want you to put together an international antimine exercise. Not an antiiran exercise. Heres where i want to point out why a Maritime Strategy is a way to stabilize an area and not bring it closer to crisis. If you dont have those and you have to send them in, that can be destabilizing. If you have the fifth out there, i thought we would get the usual suspects. France, britain, saudi arabia, bahrain, kuwait, Something Like this. In fact the first year we ran it, we got 29 nations. 29 nations included nations like a stonia, canada, singapore, japan. These are not all those nations. Remember what i said earlier, a coalition has two elements. Political and military. I was even looking to see if i can get a penguin there. All of them Work Together under the coordination of the only navy in the world that could draw on all the nations together and they all work practicing clearing minds from the persian gulf. The end result was they realized in tehran they were created in a coalition against them. How much have you heard . I havent either. Its gone up as high as 39 nations. I think there is a way that to answer your question, use that example and then you can apply it wherever so long as what we are doing is trying to stabilize the situation. We have time for one more question. Yes, sir. It has been more than ten months since iran sees one of the sailors. The navys report still is not finished. The sailors came home safe. So who won in that clash . I dont know. I dont know. I dont think its clear either way and i think the question is a valid one because out of small incidents comes an image of stability or instability of compatibility to be calling on, for example, our partners in the region to find a way to share the neighborhood with iran when the United States state department declared iran a state supporter of terrorism. I think it puts you in a difficult position when an incident like this happens to determine just where we stood at that moment and where we stand as a result of what came out of that moment. I think it would be speculative on my part and it was not something i could chalk up to a win. Thank you very much. Please join me in tanking him. Former Virginia Governor currently faces two years in prison after being convicted in september of public corruption. That conviction stems from mr. Mcdonald and his wife accepting gifts and loans from a local businessman the case is under appeal and that will decide whether its fair to classify the former governors actions as accepting bribes. You can hear oral argument later today at 7 45 p. M. Eastern. A work at the influence on shakespeare on the 400th anniversary of his death. This committee has a senator democrat from idaho was convened to the fbi, irs and nsa. And over the next weeks, we will look at portions of the 1975 televised hearings saturday night at 10 00 eastern. I cannot explain why and with the u. S. Army. Its a possible use. On the civil war at 6 00. It was not old enough. The family at that time had been living in virginia 225 years. I do not think they had the decision they believed. I think that devotion came forth in 1861. His final duty to his family. The historian, sunday morning to the white house rewind. A private decision chronicles the president ial race for the first primaries in new hampshire. The victory over the general election and 8 00 on the presidency. They can think responsibly about what one can achieve and define ones policies and understand the geopolitics in that light. Jeremy black looks at the origins of the cold war and the military man. For the complete tv weekend schedule, go to cspan. Org. Next a discussion about a new way to pay for medicare. The centers for medicare and Medicaid Services took a look at the plan at what it might mean for patients. The discussion was hosted by the alliance for Health Reform and the Kaiser Family foundation. We are going to go ahead and get started. Im marilyn with the appliance for Health Reform and i would like to welcome to you todays briefing on payment and Delivery Systems reforms on medicare. Today we will be looking at the evidence behind numerous experiments to pay medical providers based on quality rather than the quantity of services. I would like to thank our supporter in this event, the Kaiser Family foundation and in particular our long time partner, trisha newman. I wanted to let everybody know that you can tweet with us live with this event. You can tweet your questions and comments for both the people in the room and those joins us live on cspan. The hash tag is medicare demos. If you would like to access and you are not in the room with us, find them on our website at www. All health. Org. Im going to turn this over to our partner who is going to tell us a little bit more about why we are here today. Before we get started i want to congratulate you and sarah for taking over the helm of the you have been here for a while. I want to thank you for coming here today on behalf of the Kaiser Family foundation. Im excited to be here and i think we are going to all learn quite a bit it wasnt long ago that people talked about medicare as a static program. Things are changing rapidly. The long standing concern that the main problem is it only encourages more and more care has been changing and changing at a fairly rapid clip as medicare is instilling more incentives to manage care and potentially at a lower cost. Im here as you are to learn more about the progress of the demonstrations. How they will progress, sometimes these things take time and its exciting to see so much change happening and Energy Behind the ongoing effort to improve medicare. I will introduce my speakers on the far right. Christina will kickoff the discussion and she is associate director with a program on medicare policy at the Kaiser Family foundation and held a number of government positions at hhs and the medicare payment advisory position and the accountability office. Next to her is marilyn moon who is Institute Fellow at the american institutes for research. Marilyn is an economist and analyzed the Medicare Program in various capacities including for the congressional budget office. She is also serving as a Public Trustee for the Social Security and Medicare Trust funds in the 1990s. To my right is patrick conway. He is acting Principal Deputy administrator at the centers for medicare and Medicaid Services and cmmi. You will hear that a lot today. And cmmi is overseeing the payment approaches that we will be talking about today. He is director of geriatrics and cofounder of the House Call Program at med stars wash center. Eric will give us a clims of the independence at home program that is getting so much attention and med star is planning to expand to the other facilities. To my far left is jim, director of and leads the bundled at the same time program and it is acolike. We will talk about the recent work kaiser has done and the evidence we have on hand. Thank you. Lets see. Good. I am going to start with just a little context for Delivery System reform and medicare and then im going to go over very brief summary of three models and conclude with a few thoughts on ongoing challenges and opportunities. So to get right to context, i will mention a few items. The Affordable Care act brought in a large multipronged effort for Delivery System reform that created changes to the way hospitals are paid with the Reduction Program and created the office that is called that aligns payments. And the aca established the aco for the medicare shared savings program. We call that the cmmi because we love acronyms. That was really marking significant investment in testing new payment models and they gave it Unprecedented Authority and achieved specified performance on quality and spending. I mentioned that that was the passage of mac ra, the law that repealed the sgr. That was many topics. Mac ra has within it financial incentives for and this will be coming in future years. Cms is planning to release regulations in the near future and proposed rules on what exactly will be used to define the alternative payment models. That should be coming out soon. A final piece of context shifts more of tradition al payments ad i will move on quickly on to this slide that shows on the left three models of Delivery System reforms that we cover in the primner your handouts. Im going to talk about the individual models that are there on the right hand side. To distill it down, medical homes are really based on the concept that investing a bit more in primary care could lead to lower spending due to Better Health outcomes when you invest earlier. All three of the models on this slide here involve Care Management fees to the homes. And the first two specifically have a focus on coordinating mediCare Management fees with other insurers like private insurance and medicate. You can see on the map that the cluster is the lighter blue and that has more involvement with states. You can see the state is colored in. The orange dots represent the cpc participants. In those models, cmmi is playing a greater with the insurers. They are starting to come in at this time and savings are not very high, but more results are coming. They are showing some gains, but the others are awaiting more results. This is also a primary one is that it focuses to address the home needs of frail patients. The second is that it doesnt involve Care Management fees and has within it shay share in savings if they lowered spending and we will say early results from independence at home are showing promising savings. They are accountable for spending and quality for the beneficiaries. They can courteous with hospitals and the model that accounts for the most beneficiaries by and large is the mssp models. They could for about 7 million beneficiaries over 700 acos. The that the mssp models with the most beneficiaries are called track one. In that model the providers do take on risks with medicare and they can share in savings. New tracks are taken up and i would say about a quarter of the mssps shared in savings as results came out for 2014, about half of the pioneers achieved and were able to share in savings. The last model i want to note is the bundled payment. We are lucky enough to have someone who can talk about direct experience. We can characterize this as that focuses on a whole episode of care rather than payments that are made to individual providers for the individual services that they themselves provide. There many details. Im not going to get in to them, but to say that the results are very preliminary. I will just close with a few comments on ongoing challenges. We see here that while we are sitting here wanting results, congress providers and cms for sure, it takes time and there is a tension between what we want and letting the models be fully implemented as they are being tested. Finally i note that a key consideration that cms and congress will be considering as results come in is how Medicare Beneficiaries are faring and particularly those with High Health Care needs. They think some of these were designed to help. Lets learn about them in particular. Thank you. Im going to be brief and i may be talking about a onehorse pony here. That is that consumers matter and you really need to take them into account in these models. Some of the earliest innovations that occur and the earliest thoughts about innovations were often done without thinking much about consumers. Imagine an aco that is getting organized that is thinking about steering patients into different other providers and slightly different models and approaches. They have no idea they are in an acl. They may more may not have gotten a letter and in many cases they are not sure why the physician is doing that. After mentioning patientcentered care, it never arose again. Including when someone was saskd about it, they can take care of that problem. We need to change everyones minds and attitudes in the health care world. You are not going to change the system if you have a raft of patients who are heavily resistant to the change. None of us like to change when its something as complicated and uncomfortable and important as health care. Its important to get people on the same page. Air did something i was not involved with. They interviewed patients and doctors and gave them the same exact scenarios about health care trying to get people interested in quality. When they were deciding where to go to deliver a baby, they would just ask the neighbor. The reaction was why would i want to take this patience because if they are looking at quality measures and trying to steer me to a particular hospital. They were not only resistant to quality, but on a different page. There is a lot of education and they are getting much better and trying to think of ways to encourage and involve patients. Its important to keep in mind this may be a dated comment, but something to keep in mind because its easy when people are focused on the technical things to do to leave the consumer out of it. One of the important pieces that needs to be part of all of this is to ask the question, what do patients really want to achieve and when designing goals for complex care and post acute care, its important to know what the patient wants to achieve. I can give you a personal example when my husband was first out of the hospital after a stroke where he couldnt read numbers and he was very confused about a lot of things, he had a therapist who insisted he needed to learn how to dial a telephone. I kept telling her, he doesnt really need to do that. All he needs to do is push this button because we have advance that allows him to push this button. None the less, she was bound and determined he was going to dial the telephone and after about five sessions, we told her that she doesnt need to come back. There were plenty of things he could have achieved that she could have helped him with rather than the frustrations that he went through. If you have health problems, whatever it is, the patient often has a goal in getting them involved very early on. Its really important. Finally its important that they have to make sure that gets baked in rather than add it on at the last minute. This is part of the reason why it takes time to achieve savings. Everybody is adjusting to a new environment. We have to make sure they position other providers or patients are all on board before we judge whether or not it has been successful. Thank you. Is the reason we do this work is the families. At its core, we have a system that achieves Better Health and smarter spending and healthier people. Patients and families have to be at the center of care. We have policy principals we use and one is around patients and families first. These are the goals that were alluded to briefly. The president and secretary announced in early 2015 that we wanted to move at least 30 of payments by the end of 2016 and models were accountable for quality and cost care such as the aco or bundled payment. 50 by the end of 2018. In march we reached that goal ahead of schedule. That is a dramatic shift. What works and why and what is scaleable and expandible. The goal was linked to quality and cost. It is medicate and states and commercial payers, etc. They achieve that better care on behalf of patients. We have eight of the ten private payers and over 1,000 provider who is got the consumer and patient organizations and large employers and really the focus of the work is how do we agree on goals which we have and agree on payment definitions which we have and how to report on those and most importantly work on alignment. Can we agree on basic constructs on quality measures or attribution models or how patients might be voluntary. We have to set up the public and private partnership and a number of folks said this work they thought was the most Meaningful Partnership they had done in a very long time. That is the goal. They are serving about nine million beneficiariebeneficiari. 64 and counting and risk baring arrangements. You are seeing it both in the public and private sector increasingly prevalent. Improved Patient Experience and lowered cost. Organization could exit and the numbers go down overtime. The models have a much more flexible construct for people to come in and out. The next generation with the burnings of pioneer. A couple of years of adding and the first year was a tight application cycle. This is my choice. They are in the population and they received enhanced services. They can receive financial rebates for staying within network. It rewards quality. All of them focused on quality and Skilled Nursing and enabled those organizations that are ready to partner with patients and they move to a much more advanced. This can be fully populationbased payment. Moving away from the service. We are excited about the model that is starting in january. Applications are open now for new ones. Primary care, i have an update as of 9 00 or 10 00 this morning. This was the first model on the slide that did show the decreased er visited and would increase the next set of results soon. We announced this morning what we called the primary care plus which is building on what we learned. It has two tracks. I will talk more about those estimated 20 states and regions and multipayer. 25 million patients. It is the largest model in u. S. History and we think very exciting. Track one is similar to cpc, but has a couple of important changes like having the financial incentives at the practice level and more realtime delivery of incentives and payments to practice. Track two, they can move to populationbased payments. Greater than 50 coming from populationbased payments and a reduction in fee for service. It opens up that they can deliver care the way they want to and patients can receive the care when and where they want to. Sorry to talk about that longer, but exciteing for this morning. Independence at home. I will let others talk about it. I will let others that know the model better than i speak to that. Bundled payment and we have over 1500 episode initiators. They have hip and Knee Replacement and diseases that are complex. Building the connections between hospitals and connections and early results are promising in terms of improved quality and lower cost. We are working on releasing more results here. We are testing and we want you to improve quality and it includes testing reported out come measures. Directly hearing from patients about their functional status. Thats what we heard from patients and we think an exciting development. We would end on time and we will say a few more sentences. I am still a practicing physician. This is exciting work. I think we are in exciting times. Collectively we have to through as a longterm journey. We need to evaluate and learn and scale what works and i think look forward to the rest of the panel in discussion with exciting times. Fantastic, thank you. This is the part of our program where we turn to the on the ground perspective. We are lucky to have with us today two gentlemen who are right in the middle of these experiments. So we are going to hear from them. Before we do that, i want to remind anyone who is following us on twitter that our hash tag is medicare demos. You can comment ask questions that brings us to the point that after eric and jim speak, we are going to turn to a q a session. There two microphones in the room. You are welcome to ask your question. You have green cards in your folder. You can write a question on it and our staff will be around to pick it up. We have two more presentations before we get to the q a. Get your questions ready. If you want to write the questions, feel free to do so. If you are watching at home on cspan, you can tweet us your questions. We take twitter questions and we will try to answer as many as we can. Again, the hash tag is medicare demos. I will turn it over to eric d young who will talk about his house calls, independence at home program. Im going to start off with a disclosure on the front slot. You are talking about homebased primary care and a house call model for frail elders and how that led to the independence at home model and Demonstration Program that has been successful in the results announced so far. The disclosure and my presentation does not involve cmssponsored analysis and its my verification by them. How many people have an elder in their life who is sick and has trouble getting to the doctors office. More than half the room. Independence at home and homebased care is the model for those people. 17 years ago, the doctor and i came to d. C. And decided to set up a clinical model of care for those folks who are frail and have trouble getting to the office. That would follow them and talk about the details. We wanted to look at the effect of that model and a mobile teambased approach to care in the home on quality of care. The experience and the cost of care. I would say its a secondary out come. The impact on the patient and the family. We will talk about those results. I want to close with talking about whats next. This is a highly targeted clinical service. In contrast, they target less than 5 . They age 66 to 110. The 110yearold was born on january 1st, 1900 at the beginning of the century. This is the kind of folks we take care of. The service is simple to describe. Hard to execute. 247 availability. Its not just about house calls. You coordinate all services that they need. Medical services and social services and subspecialty and transportation. The goal is enhanced for health and dignity. Bring peace of mind. The independence at home model based on systems across the country allows the teams to be scaleable. The independence at home allows it to be scaleable. This is very strict criteria for eligible patients. You have to be frail, disabled and had high cost in the past year. There is a high bar for the program. You need to have all the researchers in place to take care of the complex patients. You only receive savings only after you achieved 5 reduction in medicare costs. Until you have greater than 5 reduction. Providers would get 80 percent per of savings beyond that first 5 if they mead all six quality metrics. The orange at the top on the left is the number of beneficiaries, but they expend nearly 50 and similar to the commercial payers. We will talk about a patient who had liver and heard failure. She had six admissions. The daughter moved her mom to a d. C. Zip code to gain gree. For the last years, she received over 150 house calls and coordination and a lot of home xrays and ekgs and wound care and many visits by the team. A lifesaving massive hemorrhage and we thought she was going to die. We used the high level high tech care to do a last minute procedure. She has been home again for 18 months. She had two admissions. 5 per patient year. She has been four years older and sicker and has not been in the hospital twice. She had another er visit. How does this work . This is a busy slide. I wont read it all other than to say the Home Based Care Team has to coordinate everything. Its a direct team of people coordinating everything they need overtime to the last day of life. We coordinate visits from the weekend and had about ten unstable patients. They are making house calls to prevent the visits and keep people at home. We direct the hospital care ourselves and we can manage the discharge at home. We are available as are all of the programs that have to have a 247 availability. The next six are the things you can do at home. What is possible . The hospital really is for intensive care, surgery, procedures, complex level of things. You can do almost Everything Else at home. From radiology to equipment to iv therapy to iv fluids. As long as you coordinate the services, you can have a reduction in cost. It restored her system and the good days and hours and moments are the result of the passion and excellence of those who created the program. I am going to close with the results. This is the study that came out and the highest rate of the program is 12 lower cost and the study of our program showed similar mortality of both controls and cases and 17 reduction and fanlly the independence at home with year one results. They 20 reduction of about 1,000 per patient month. Close to 12,000 per patient year. Nine of the 17 were paid savings. 25 million was saved and 12 million returned to the providers. What are the challenges Going Forward and finding the workforce is the number one goal. Its doable and you have to have a Financial Model that will support them and build a lot of practice capacity to support these teams. All the other service partners. You have to have a Health System that will commit to doing valuebased care. Med star health in the midatlantic is building a new team in baltimore based on the independence at home results and both the quality and the cost savings because they have faith that cms and others will reward this kind of care. How can you all in this room help . We are working with the house ways and means to turn a permanent part. Link savings to neighborhood metrics. They have been working hard to target the right patient who is have persistent high cost and use the criteria for the new practices who roll out across the country and use adjusted methods so the results are fair to both the government and the provider. Heres a picture of the team. This is the most important thing we do that we have every day. This is a team of 20 people who are here who do this work and finding the right people is the key to success. I have the privilege of sitting in on a team meeting and shadowing george who is your partner in crime. This is teambased approach and collaborative and using people to do what they do best in different capacities. If i had someone who was old and sick and impaired, i would be thrilled to give you a call. Thank you. We will move to jim who will give us his own perspective from the Rochester Medical Center where they are trying out bundled payments. Jim . Appreciate the time to be here this morning or this afternoon. I want to just level understandings of what bundled payments are. Its a single budget for an episode of care. We think about the episodes and we had a definition around that. It starts with in our case an inpatient admission and the anchor admission and it goes out beyond out to 90 days. There options for less time than that. Everything that happens to the patient after they are discharged from the hospital, inpatient, nursing home and those kinds of things. There was a term used earlier about what they said was the patient comes first. Not just because i am the director, but if you think about Knee Replacement surgery, i have Knee Replacement surgery, i think bundle starts when i go to my doctor and i say you know what, the injections are not working and the medication is not working and it ends when i get to go back to golfing and now i have a better excuse for how bad i golf. Thats the concept of what Knee Replacement is and how patients think about it. Its not how we finance or pay for it. I think it is a much more patientcentered viewpoint. If we are at risk, we reduce the variation. We started with do we have volumes that would indicate its worth doing and variations that say there is something to reduce that variation and improve care and reduce cost. This is a financial arrangement and a tractortrailering arrangement, its a clinical practice and program. We had to go to them and we took the data which was great and went to the Service Lines and see potential opportunities to reduce cost and dip our toe into valuebased payments. What would you do differently to go after this opportunity . What could you achieve . Not only do we think we can get this done, but we have the Clinical Knowledge to get this done, but do we have the leadership to get it there . This brought it down to the major joint replacement as one opportunity and congestive Heart Failure as the other and these were different programs. This is our base line data and this is an episode. It doesnt take a Rocket Scientist where we need to focus. It is Skilled Nursing facility. 74 were going home with Skilled Nursing facility for the rehab. We can do better than that. Congestive heard failure a different story. I look at that and whats red and how can we eliminate it . The whole thing is keeping people from coming back. If any of you have anybody in your that has congestive Heart Failure, its this constant revolving door. We nailed down what the objectives are. We start with the in patient side. We have the right folks in the room, but b this this is not jt improving care. We actually brought the post acute folks and say work with us and help us understand these patients and figure out what we do, but what you do on the post coordinated plan of care across this continuum. We have a couple of resources. One is a dashboard, which is just a way to a place to put people. Its a software package. We can keep track of the real key is the care navigator. One person who has specific focus and responsibility to watch these folks across the continuum of care. Not just in, okay, here we are done at the hospital, here you go. Its continuing that process all the way through the end so they are there a single point of contact for patients and for providers. Then the other major resource we applied was enhanced home care. For joint replacement, clearly it was getting rehab done in the home with home care and not in a sniff. For congestive Heart Failure, different approach. Its all about applying those home care resources in a rapid environment so that instead of picking up the phone and calling for an ambulance and going to the ed and back up to the hospital, its you call the care the nurse navigator or the nurse visiting Nurse Service and say, come out and do an assessment. They can bring telemedicine resources so we can do a consult with cardiology on site and even administer iv medications if thats whats necessary to keep folks from coming back into the hospital. So results. We all care about results, right . This is major joint replacement. Green line is rehab. You see there were 74 at baseline. We set a target for 25 . We have already blown through that. But thats not enough. We want to make sure were not doing that and then people are coming back into the e. D. Or back into the hospital because instead of being in a snf where they are getting good care, they are home and not getting the care they need. Our e. D. Visit rate actually went down. Not only did it not go up, it went down. We are very encouraged by that. And we did then the cost curve. We did achieve what we were looking for. We think we can do better. Congestive Heart Failure, completely different population. We have not yet really solved the readmission problem but theres one shining star in this. Remember, we said we had this clinical pathway and part of that was home care, enhanced Home Care Services to this population. So if we look at just the population that went home, didnt go to a snf, the people that went home with no home care which means they were offered and refused it, they came back at least 40 of the time, 47 of the time, they came back at least once. If they went home with a Home Care Agency that was not one of our partners, they came back 43 of the time. If they went home with our partner Home Care Agency that was committed to applying those rapid resources and doing telemedicine and iv lasix administration, the medication we use to control fluid retention, 17 of the time they came back. So theres a glimmer of hope here and i think if we just keep focusing on that model i think we will do better. So i just want to, in the 30 seconds i have left, i want to just say theres one piece of this that im really excited about, and sort of the spillover effects and the Lessons Learned, and that is you would expect the clinical leaders would all be about hey, lets apply these resources, great resources to more than just the medicare bundled payment folks. So we have had that. We expect that. What i didnt expect is i have just as much attention from the administration of the hospital saying how can we leverage this to other patients, we have a unique opportunity here to really improve the quality of care that were delivering, reduce the costs that were delivering. How can we figure out a way to afford this to broaden it out to other populations. Thats a really exciting place for a policy wonk like me to be, because usually youre trying to drag along the culture and instead, im seeing the culture change before our eyes. So i will end with that. And we will take questions. Great. Thank you for that very, very specific information about these on the ground programs. Its incredibly helpful. We are now open for questions. I invite folks in the room to come up to the microphone. I invite anybody who would prefer to write a question on the green card and our staff will be around to pick up your questions and bring them to us. If you are at home watching this live on cspan, please tweet a question. Anybody in the room can also tweet a question. Again, the hash tag is medicare demos. While we are getting folks set, i will turn it over to trisha to kick us off. I think i have this is a question for patrick. We did some work a few years ago that looked at people who live in nursing homes, so people on medicare who have very high rates of emergency room use, they go in and out of the hospital, they are high medicare spenders even though we dont think of medicare as the place for medicare spending for nursing home residents. I think there may be two demonstrations, a new one and an older one. Could you tell us a little bit about how they are moving and what the early evidence might be . There are two. They are both managed by Innovation Center and the office that was alluded to focused on beneficiaries in medicare and medicaid. The first was around evidencebased practices and implementing those to decrease admissions and readmissions. We did see early evidence of a decrease of admissions and readmissions and higher quality, but early in that program. Then we overlaid a financial incentive on top of that model to really reward financially as well if we were able to prevent admissions and readmissions. This is a population that we care about deeply and two models that have not been certified for expansion yet. But the early results are promising. Great. Lets move to the microphones. Im dr. Caroline poplin. I have a specific question for dr. De jonge and a more general question. The specific question for dr. De jonge is home health visits. My understanding is that congress has been cutting the amount of money for home health because they think theres a lot of fraud in the program. The fraud that i have seen, because im also an attorney, is forprofit Home Health Care provided to people who dont need it while avoiding the people who do need it because its expensive. My question for the panel is along the lines of marilyn moon, is value for whom . I know value is supposed to be quality over cost, but are the patients involved in the quality measures, and i dont mean Patient Satisfaction surveys, because for a healthy patient, thats parking, and ability to schedule, and to call the doctor at night. And for a sick person, its time with the doctor, to ask all the questions and get the explanations and get some empathy. Yes. There are two questions there. One is just about Home Health Care. The medical house call home based primary care model taps into skilled Home Health Care as needed. We have found many very good ethical High Integrity Home Health Care agencies we work with. We use them when we need them for episodes of care, but they are part of the team in the ih model. Then in terms of could you restate your second question . The second question has to do with value. When we talk about substituting value for volume, i guess youre talking about quality over cost, but value to whom . From my perspective, independents at home looks at this as well, value to the patient and family in terms of their goals, their outcomes. One of the six metrics thats directly linked to savings is whether the patient and familys goals and preferences for ends of life care are documented, whether they receive a house call within 48 hours of going home. So its value for the patient and family first, and then value for the payor in terms of being able to afford the care. I think it has to be both. I would like to hear dr. Conway address it or some of these other people who are involved in the Program Setting them up, setting the quality measures, whether patients are involved in the quality measures. Frankly, i dont care how many mammograms my doctor has ordered. I think youre making a good point. I think one of the things that makes most sense to me when you look at these models is to think about whether or not theres actually both flexibility and coordination that goes on, because then you are talking to the patient and you are getting involved in what the patient wants, and it seems to me that in terms of achieving those goals, the kinds of things that we were hearing about both in terms of the bundled payment and the independence at home have a better opportunity to do that than ones that are really focused on, are more technically focused and dont involve the patients as much. We do have patients on the various Quality Measure Development teams and committees that review quality measures for implementation in various programs. It is critical. So lets move to the other side, if you could please identify yourself. Im joanne lamb from the Institute Center for elder care and advanced illness. Im delighted that we are on this journey. I feel like we are sort of lewis and clark in their first winter, knowing where theyre headed, sort of, but having no idea how far away it is and what they will encounter. But i think that really continuing to work on what it is were trying to get to is an important part of the endeavor, because some of what we are now doing may make it harder to get to where we hope to go, and in that light, let me invite folks to weigh in some on where it is were going. We talk about total costs of care as if thats an obvious idea. We are only talking about total costs of care in medicare. The big issue is Longterm Services and supports and especially family care givers. When we cut out all the snf days and were terribly proud of it and sharing our profits with the providers, we forget that means families have to take people home much sicker still with their wound clips in, still unable to do a twoperson transfer and someone has to cope with that. Someone loses work. The care giver, the average woman family care giver loses a quarter Million Dollars toward her own retirement by taking care of her mother. Thats big. But we dont account for that. The big issue is not its a big enough issue just what were going to do within medicare, but medicare has this huge kind of semipermeable barrier with Long Term Services and supports and its even bigger especially if you start counting family caregiving. If we start counting quality measures in that arena we get into things like people not wanting to be bankrupt, not wanting to lose the ranch, not wanting to be a burden on their kids or grandkids. It seems that the vision like lewis and clark trying to imagine the pacific has to include some real end point that isnt just paying providers for doing what they ought to have been doing 20 years ago. Eric and george started their effort 20 years ago. We knew then what we needed to do. It seems that we really have to start kind of planning these modifications in light of where we hope to get to and that it seems might require thinking in terms of small localities, at least for these very sick people. It doesnt matter are you going to a question . I want them to weigh in on whether this seems to be where were going. One of the directions for movement would be to really take account of the seriously disabled, seriously frail elders in a geographic community and build the capacity more broadly there. Much of what we are now doing makes that harder to do, because we are building, financing and quality measure lines that do not support that endeavor. Lets see if we can get a reaction from the panel here. Anybody . I can take a little bit of that. You bring up a really good point and i think it deserves a lot more than i have the time to address today. Let me just give you just a small sliver of what were doing. So we dont simply turn people over to their home and say here you go, good luck to you. It actually starts well before the surgery, when we are talking about joint replacement. We actually go out to the home, meet with that person, meet with their care giver and plan their discharge with them and their care giver jointly so it is not just our decision to say youre going to go home, its a joint decision with the patient and their care giver and the provider. So you are absolutely right, we cant just kick people home and expect that the familys going to pick up the slack. Great. Lets move to the other mike. Did you have a comment, patrick . You obviously talk a lot so i wont give a long answer. I think we are trying through Accountable Health communities through some of our medicare transformation work including on Longterm Services and supports and some of our state innovation work to start to address more of these issues and the Holistic Care paradigm including out of the provider system and really testing models at the Community Level to improve health, and health outcomes. I think its a fair point that we have more learning to do in this arena about how to do that the best way possible. Great. So thank you. Lets move to this microphone. Thank you. My name is amy gibson. Im with the Patient Center primary care collaborative. I want to build on some of the comments marilyn, you were making about how we get buyin and why buyin among patients is critically important. One of the things we have come to realize is you really need to have them involved as partners in the design of the program from the very beginning. We just heard from a panel of patients in a conference in chicago, from a patient who reminded us that quality is assumed by patients. So when they are going to get advice on where to go to get their best care, they are not necessarily looking for a four or five star rating that shows them that the quality is good, but rather, as you address, that they are going to their friends to find out did your doctor really listen to you, what was your experience in care. I think if we have the conversation with patients around improving experience of care, and they also absolutely understand value of care. Dr. Conway, i certainly want to first and foremost applaud cms for all that you have done to demonstrate how important those collaborations are from the very beginning. Our organization is funded as an Alignment Network specifically to facilitate these collaborations and Meaningful Partners with patients and families in clinical redesign. Dr. Conway, i just want to kind of have you talk about that and some of your learnings and how cms is starting to evolve those relationships and even through the expansion of programs that are successful and new programs that youre developing, what are you doing to better assure that there is that collaboration Meaningful Partnership with patients from the very beginning . Yes. Thank you for the question. Its a critically important issue. A few things were trying to do. One which was talked about earlier, the sort of quality measures and whats the quality focus. We think patients and care givers are the most important voice in that equation. We are doing this now and i appreciate the positive comments. I think we need to continue to do it better. How do you engage patients and families really in the design as you said. And the life cycle of the model. And i think this is something we have met with a number of groups, thinking through this, and how to do it more systematically so stay tuned for even more. I think we agree with the concept that you want patients, people, consumers, families and care givers to use all terms to be as inclusive as possible to help design these models, to be cocreators both at the start through the evolution of the model as we try to improve models and in aspects of evaluation such as the quality measures involved. Thank you. So lets move to a question from one of our green cards. We actually have a few questions on the issue of how well does all of this work in rural areas. Several of the demonstrations we have heard about are sort of well suited for areas where theres a concentration of people and providers, i think theres a story in the paper this morning about some of the challenges that people in rural areas face, especially seniors. I think a quarter of all people in medicare are living in rural areas. This is really for anybody in the panel. We have talked about scaling up things that work. Do they work in rural areas . This is eric de jonge. I think independence at home can work in any area of the country, rural, suburban and urban. The challenge is how do you staff it. In arizona and new mexico, theres an ih life kind of Home Based Primary Care Program that uses more televideo. These are slightly different staffings. The doctors are sometimes more consultants but you can achieve the same goals of keeping people at home, using mobile technology with a slightly different kind of staffing mix. But i think this can be done in any geography. Just building on that briefly, this is an issue we focus on significantly. I think the primary care models can be done in rural areas. We did advanced payment, other methods in our program which had the vast majority in the last round of participants were small practices or rural practices to help with the transformation work. We also are engaging with a number of states that are thinking about Population Based payments for rural areas and what that might look like. More work to be done but a number of these models with work successfully in rural areas and how can that be done. Yes, at the mike. My name is jenny boyer with Health Net Federal services. We are the contractor that manages tricare in the northeast. Might pull the mike a little bit closer. Sure. My question, especially to those of you who are involved in making policy, all the pilots are great when its well known and high quality facility for a small area, but how do you scale that for the whole country and what happens when the quality inevitably deteriorates . That might be for me again. So a few thoughts. One, the majority of our pilots are voluntary, either community, state or provider pilots. You are seeing a number now like the joint replacement which are testing in a Geographic Area including all providers in a Geographic Area. The sequence there as we saw early positive results in the joint replacement model from the bbci, the bundles model that was talked about. Now we are testing a Geographic Area to learn what you just described. Will the results be the same in a diversity of providers. We do have monitoring, we are trying to minimize unintended negative consequences and trying to eliminate them if possible. We have monitoring, we have the ability to pull people out of models. We have other tools we use when we have major issues. But i think you need an array of testing strategies. You picked up a lot of the early doctors and now we are moving to the big middle and shifting the curve as was alluded to. Its how do we now learn in this sort of big middle of transformation and what works with the big middle, if you will. How does context, sorry to answer long, i try to be brief. Its a good question, though. Context of the providers really matter, et cetera. So we are trying to structure this now in a sort of stepwise progression that picks up an increasing number of states, communities and providers across the country, including ones that maybe historically werent high performers but want to be high performers in a population of construct and lastly, sorry, supporting people. We are making Major Investments through transforming clinical practice which was alluded to and other initiatives to support various providers states and communities to improve. Marilyn, could i just add that i think that not only do you see in the beginning that high performers but you often see the highly motivated and ready to change folks. And its the not so ready to change people that you worry about then bringing these two. So im glad to see dr. Conway talking about the importance of them providing Additional Resources and providing education and information to people, because they the leaders already are motivated to change in many cases and its the folks who are just not sure thats what they want to do or are skeptical that you need to bring along. I think that is a really important aspect of the next stage of all of this. Thank you very much. Great. We have another question at the mike. Hi. Im carl poser, cochair of the Long Term Care discussion group. I really enjoyed the presentation about the independence at home program and the savings to medicare and the quality of the care. But i thought of this question before the other two questions. But its sort of a followup. What do we really know about the incidence of Long Term Care medicaid costs and the burden of unpaid care giving around and if you dont have specific studies, whats your sense . Does it also save in assisted living, nursing home and home care, long term Care Services or doesnt it . And what about the needs, you know, the pull on the unpaid care giver . Sure. Thank you. So in our practice here in d. C. , we have a less than 5 incidence of nursing home placement per year, so about 95 plus of our patients stay at home long term. Thats much lower than kind of the benchmark around the country for this population. We havent done the medicaid cost analysis. Theres actually a number of both at penn and i know within cms some interest in doing that. Our experience is if you have social workers on the team as we do and you have the true interdisciplinary approach and get the care for the care givers and the patient in place, the kind of amount of nursing home placement and then therefore medicaid costs significantly less. Im afraid this one might be for dr. Conway, too. Maybe anybody else want to join in, that would be terrific. Everyone including president ial candidates is talking lately about the problem of rising drug costs. How will these demos address the problem and are there any particular demos that directly address this issue . I think i know from where you were speaking this morning that you have a specific demonstration to talk about. Yes. So a number of the models before i talk about the specific one do include drug costs, typically b costs, but next generation even includes the possibility of organizations bringing in d costs. Our own care model which we had Robust Interest in, we look forward to announcing the participants, also includes both a and b costs so includes drugs. We do have a part b model which i spoke this morning about that directly focuses on paying for value and better Patient Outcomes in part b. I want to say clearly it does not limit access. We do not believe the proposal limits access for any patient to get any drug they need and any physician to describe any drug they think is warranted. If there are examples that people can provide around limiting access we would want to know about those because access and focusing on better Patient Outcomes is a core principle for us. Its a proposal we are seeking comment on that we could be directly aligned with paying for value in the drug arena. You have another question at the mike . This is Christine Grossman with the alliance for specialty medicine. I actually had a question actually for jim. I used to work at cms actually up until quite recently. I had a question on your bundled payments portion. So you talk about the episode of care lasting until 90 days post services. I heard you have several docs both now and in my previous position in the past at cms having issues in terms of following up with patients and you know, getting information past 90 days. I wanted to see if you all account for that and you know, what you do in terms of if a patient doesnt follow up and how that computes into bundled care. Patient followup is a huge issue for us, particularly for the congestive Heart Failure. I will tell you a little bit of a story. This is only tongue in cheek. One of the medical directors of the congestive Heart Failure program said that if he could find a way to combine the oral lasix medication which is the drug we use for fluid retention with crack, then we could get our patients to be compliant. He was only halfkidding. So when you talk about patient followup, we have care navigators that are constantly calling and visiting folks to try and get them to come into those followups which is one of the reasons why we have initiated Telehealth Services through the visiting Nurse Service so if they cant get back to the clinic for their followup appointment, we will go to them so they can have that visit wherever they happen to be. But patient followup is one of the hardest things to do in this population. Thanks. Okay. Thank you. So to follow on that, lets talk about additional implications for patient involvement. So there are some pros and cons associated with passive enrollment in these models of care. What are the implications of more or less patient beneficiary involvement . I can comment a little bit more as an analyst looking a bit like you said at the pros and cons. Id say and while some models are being introduced in the future that allow more Patient Engagement, some of the ones we have results about now have more the passive attributes. I think some of the thoughts behind that are that in the one hand, its not very disruptive to the patients. This is going behind the scenes through claimsbased analysis, and then it in fact places greater a greater role for the providers to really engage the patients and work on the care. And also it eliminates some of the selection issues that i think marilyn sort of brought up, where although this is more i think some of the thoughts behind that are that in the one hand, its not very disruptive to the patients. This is going behind the scenes through claimsbased analysis, and then it in fact places greater a greater role for the providers to really engage the patients and work on the care. And also it eliminates some of the selection issues that i think marilyn sort of brought up, where although this is more the patient selection, where patients, whether they be recruited or not recruited, so some of the passive enrollment from an analysts perspective has some merit. But on the other hand, youre losing by this passive attribution, youre losing patients volunteering to be part of this model and then being more proactive in listening to the care decisions and making choices about which providers might in fact be higher quality, lower cost. So i think there is a push and pull, and i imagine that the future models that are coming are going to be assessing both that push and pull about selection issues versus Patient Engagement and patient involvement. And for some, it could be both. That theres both passive populations plus active choice populations on top and so we do want to learn how to do this best and whats the sort of deepest level of Patient Engagement necessary and i think just to build on the answer which i agree with, on some models it may be both. So i want to note, we have 15 minutes or so to go through to get through more questions, but i want to point out that in your packets you have a blue evaluation sheet and we would be very grateful if you would take a moment to fill it out. We have actually made it a little bit shorter so its easier to fill out, so we would be grateful if you did that. This is not an invitation to leave. So i would actually like to ask patrick and the others up on the dais to look into the crystal ball into the future, into the next year, into the next two years, to give us an idea of whats coming next, whether it be expansion of some of the programs we are already seeing in demonstration projects, whether we are expecting to see some new kinds of programs that are bubbling up that arent necessarily part of the demos but they are starting to come about in the private sector, what will be the focus . What do you all see coming down the road if we look ahead . I can start on this. So great question. First, at a high level, i actually see the level of transformation accelerating and my prediction is that may continue in a positive direction. I think im seeing a cultural shift. Three or four years ago i talked to a big group of ceos about this and i could tell yeah, yeah, that may happen some day but not that worried about it. Including a very tangible example where the person said i will never be in one of your models and now are in a bunch of our models. Its because you have seen a cultural shift that people know this is where were going, its the path were on, we need to learn how to get there. I think the progress will continue. Regardless, Delivery System reform i think is truly bipartisan. Then on the details, three things. You will see increasing we announced the certification of the Diabetes Prevention program which we havent talked about today. A few weeks ago, i think you will see increasingly results that meet the bar for expansion and therefore expanding the program. You will also see us take learnings from programs even if its not formal expansion and propose them into various programs. Two, i think you will see continued models that fill gaps like the conference and primary care plus model today. We are working on direct consumer oriented models that are complicated and hard to get right but we worked on health plan innovation which we havent talked about much today. The drug space, you have part b model thats a proposal. You will see gap filling. Then three, i think this private sector Public Partnership aspect you will see accelerate. Increasingly when i interact with private payers in states and Medicaid Programs theres agreement on this is where we need to go. There is actually agreement on a lot of the high level payment models. I think you will see a shift across the public and private sector which i have been on the provider side and had to deal with, makes it much easier to succeed if you are getting a common signal across your payers from your state, et cetera, about moving to this alternative payment world. I would like to talk about how this will affect things. I think the argument for increasing impetus for change comes from the demographics of the baby boom population turning 65. Much more accustomed to questioning authority, much more accustomed to being skeptical about being told something by a physician, for example, and with all of the attention and publicity around change, i think recognizing that change is not only going to be coming but that if people want to have a role in it they need to be fairly active. On the passive side or the more troubling side, we will have an increase in the population of Diverse People on Medicare Program than we do now as increasingly the the number of latinos and African Americans increases the share on population and that means that you have a bit more of a challenge in reaching out to those people that have a different cultural background on the hispanic side where we know from a lot of research that people behave differently and respond differently and interact with the Health Care Providers differently. Thats going to mean unless we reach out and try to provide good outreach and education there will be some problems there. It can be on the one hand and other hand, i guess. There will be some work that needs to be done. I have one more change that i feel that i see has come up here and on the panel and thats you how the workforce. I see that changing a bit where we have the navigator with the bullet wounding thats mentioning in rochester, and we have the Community Health workers involved in hospitals in the paper today. I think in the rural areas that came up as a question, theres different models that may have the ability to coordinate care across the settings and that may go hand in hand if they find ways to marry those in the workforce. That needs to be cultured. Theres other systems to develop that. I have a question which is were talking about changes in traditional medicare and really learning from different models in order to improve the way that care is provided. I am wondering how all of this relates to what is going on in the medicare world and whether or not some of the Lessons Learned are being applied to the traditional medicare and the things that are working in traditional medicare and being injected into the medicare space and how would a beneficiary know . Yeah, so ill start. Others can jump in. And were having this by learning and approaches and then describing briefly further. So theres an example of the model and then the value base design that we launched in the Medicare Advantage and seen that in the private market and thats bringing the market and testing them in the medicare market. I interact with the Medicare Advantage and through the various clinical quality and innovation leader. Were learning from them on the work that theyre doing as well. I think that like wise theres examples and acos and bundles and primary care where were sharing directly and doing with other pay ers and encouraging them. We can encourage but not require which is appropriate. Encouraging the various medicare plans to adopt or consider adopting the various models, and were seeing that happen. Youre going to see the way that Medicare Advantage plans pay providers and increasingly converge over time. This is a quick follow up and thats at home and its the high cost of people that are living in the community. Is that something that is part of the care system that Medicare Advantage plans are providing as far as you know working with the medicare plans to be sure that the best practicing are being replicated for the the beneficiaries no matter which Delivery System that they choose. Can i take that up. Programs are having contracts with medicare and that cover s the cost of the program and gets them into the black and now doing that care as we speak. We have the medicare plans and commercial plans. Mine transform the advance care, and these models are great hopefully they will continue to be successful, but how will we coordinate these models and if theyre an elder that needs a hip replacement, youre can an aco and then at home and a bundle payment . I know that they need to be the from an evaluation standpoint, but how is it going to come together . Can i just say from the doctor perspective on the ground i think that the Patient Population has to drive the Financial Models and the payment models, so you have a lot of models and in this program, we take care of the patient from day one until the last day of life, and all of that care is an in dependence at home. Were not in an aco because right now theyre exclusive. We do not participate in the bundles, so ih is a stand alone program. Thats how it is now. We have the alliance and we will continue to work on those you issues. What we will find is the financial mechanisms that are working and become how theyre paid for and organized. Were going to have to work through the the issues. We did this a few years ago and then bundled together. We think that theres a hope for consumers and the whole idea and thats why its important. And theres the type of lung term and so in event its going