Transcripts For CSPAN3 Representative Michael Burgess Discusses Health Care Policy 20170114

Subchi on healsub c committee on health talked about the health care policy. This is just over two hours. Okay. I want to thank everyone for attending this event today. Im joane antos, for the policyt the institute, on behalf of the Business Group on health i want to welcome everyone here and everyone watching remotely including those watching cspan to todays conference. We are going to discuss the challenges of providing high Quality Healthcare that is affordable for patients, employers and taxpayers. This is clearly a critical topic for government policymakers. The recent election obviously highlighted the disagreements among many people in this country about whats the best way for government to proceed in this area. Obviously, changes are coming. The expansion of Health Insurance coverage under the aca has come at a steep price and the Incoming Administration is looking for ways to get costs under control while insuring people continue to have access to Health Insurance. Employers have long been at the forefront of this struggle for affordable healthcare. About 10050 Million People under the age of 65 are covered by health plans sponsored by employers. The average premium for a family covered by employers was over 18,0 18,000 last year in 2016. A nearly 60 increase in total premiums since 2006. Health benefits are a major component of Employee Compensation and the rising cost of Health Benefits has slowed wage growth for millions of americans. As health costs have increased, large employers have vested in Innovative Strategies to promote value and control cost through patient engagement, provider payment reform and deliver system improvement. We will discuss some of the initiatives undertaken by four large employers, initiatives to promote more efficient Healthcare Delivery and lower cost. What can we learn from their succe successes . What can we do to help resolve the problems they face in dealing with cost and quality problems . What is the role of government promoting effective private sector initiatives and what are the barriers that need to be lowered to make those efforts more effective. These are the themes to be addressed by our two expert panels coming up shortly. To start the discussion we are honored to have dr. Michael burgess, chair of the Health Subcommittee for the health, energy and commerce committee. Dr. Burgess represents the 26th Congressional District of texas. Equally important he is a practicing physician who cares deeply about meeting the needs of patients. From burgess has been a strong advocate for legislation to reduce healthcare costs, improve choices and insure we will have the capacity to provide appropriate medical care to all who need it. He also played a key role for the medicare system for paying physicians intended to create better value and affordability. With that, dr. Burgess, please join us. Thank you for that kind introduction. Thank you for the invitation. Thanks for allowing me to be here. If i understand my task correctly this morning, its to talk about innovation and policy. Does innovation inform policy or does policy inform innovation . The answer, of course, is its both. We might look to a couple examples why it is perhaps more satisfactory when innovation drives the policy rather than the other way around. As we sit here, theres really not much happening right now in washington, right . Not much happening in healthcare, kind of a sleepy backwater policy subcommittee that im going to chair this term. Its a financiphenomenal opporto get things right and provide for people in a way that has never been provided in the past and also an opportunity where things could get much more dangerous in the days and weeks and month ahead. Thats kind of the challenge thats certainly before me as a member of the subcommittee, individual member of congress and someone who represents 790,000 people back in north texas. My life has been in medicine before i came to congress, so when i think of things like game chan changers in healthcare, i typically think of discoveries and devices, drugs that have been developed and how they have changed medicine. But as we take a step back this morning and think about over the last 20 years, two things in my opinion profoundly change providing healthcare for people that actually didnt have a lot to do with things in the laboratory bench. 20 years ago last august the Kennedy Castle balm bill passed. Although there was a lot of things in the bill, one of the little projects tucked into that bill was the ability to provide Health Savings accounts. They were capped at 750,000 of those that would be allowed in the term of the bill. I wanted one. I was afraid i wouldnt get my stuff in in time to get one of those 750,000 Health Savings accou accounts. Turned out i needen the have worried. There were plenty to go around for any who wanted them. They were not all that flexible back in those days, only one or two insurers in my area that would talk to you about that phenomenon of a Health Savings account. When you stop and think medicine is there can be an unlimited demand. I know this. I used to practice medicine. The barriers that should be pla placed, should it be placed by the government . Should it be a waiting list . Should it be rationing . Or do you want some sensitivity, feed pac on, yes, the physician, but primarily the patient i believe should be in control of that situation. The Health Savings account is the perfect model to allow that to happen. Last night in the rules committee we were marking up the budget that will allow reconciliation and allow repeal plus when ever it comes down the pipe from the committees. In that, a question was posed by a democratic member from florida, i challenge any one of you on this rules committee to point to me a year where your Health Insurance premium went down. Ill be happy to. Its the day i got a health s e savings account. My Health Premium dramatically reduced. If i had the discipline to put some of that money im not sp d spending on a premium into a tax deferred savings account, that was 20 years ago, over that time span, theres the ability for me to garner a significant nest egg against medical expenditures, i would argue whatever we do next i would like to see expansion of Health Savings accounts as a not for everyone but a fundamental part of policy i would like to see that happen. One of the things were hearing a lot right now, another issue that came up yet late last night in the Rulings Committee markup, another democratic member from massachusetts said 20 million, 30 million, whatever the figure of the day is, are losing their Health Insurance. I dont recall that individual being terribly concerned when i was one of the 6 Million People that lost my Health Insurance at the end of calendar year 2013. I had a Health Savings account and high deductible policy. The president told me it was a junk policy and i had to get rid of it. He knew better. This is what i had to buy there were 10 essential Health Benefits that were covered and might not have been covered in the policy i had. Where was the concern to people losing those policies when the Affordable Care act happens in january 1st 2014. I will tell you as it was implemented there was a special deal for members of congress. I thought that was wrong. The special deal for members of congress was we could take a subsidy and walk it into an exchange as long as we were willing to purchase in the d. C. Shop exchange. Number one, my doctors are not in d. C. , theyre back in texas. That was of no real value to me. The other thing was i knew my constituents at town halls back in texas would not understand why i as a member of congress not a special subsidy untaxed i could walk into an exchange. I said, i cant do it, no thank you. I went to healthcare. Gov and signed up just like so many people tried to do that october, november, december, it was one of the most miserable experiences ive ever had in my life. I was worried i would get signed up by the time the deadline expired at midnight on december 31st. Remembery they extended it a few days. It was a tense time for people buying in the individual market. It was an appropriate thing to do because my constituents i represent who are in the individual market are going through the same thing. Ive heard from a lot of them over the course of time with the Affordable Care act. Two or three days ago the president gave a beautiful address in chicago and talked about how great things were with healthcare. You almost feel like youre in a dickens novel, its the best of times, its the worst of times. Look, people are struggling right now under the constraints of the Affordable Care act. I view myself as on a rescue mission here to try to help people who have in fact been hurt by the federal policies that have been imposed. Again, the other thing that happened over the last in fact 10 years ago, 10 years ago last week, the introduction of the iphone. Now, you dont think that is a startling medical discovery but my iphone can take my ekg. Cant yours . This morning just to make sure because i read a lot of twitter reports on the rules Committee Last nighty this guy has no heart, i thought i better assess whether there in fact was local activity in the myocardium. Im happy to report there was. In fact, on my watch that talks to my phone, theres a little icon i can actually click on that icon to get the ekg function of the phone, except when i do that, it says, this function is not available in your country. So maybe thats something we ought to work on from a regulatory standpoint. Think how life has changed in the last 10 years because of the handheld devices, smartphones we all carry with us. Mine will take my Blood Pressure, take my assessed blood sugar and check my weight. Im worried the nsa has hacked into that and altered it on me. I practiced obstetrics. Back in the days i practiced obstetr obstetrics, it never failed, 4 30 on a friday afternoon a patient would come in her last two or three weeks of pregnancy with a Blood Pressure just enough elevated over what it had been before to cause some concern. Heres the problem. Most people who have that, it will turn out to not be a problem, may have been because i didnt have enough parking pl e places close to the office or she was mad at me at the time the Blood Pressure was measured. Bad things can happen. If you go the ultra careful route and say you have a Blood Pressure measurement higher than it has ever been before. I need to put you in the hospital and monitor that. We did that a lot. Late in pregnancy, in order to assess or make sure that preeclampsia would not lead to eclampsia and all kinds of bad things down the road. If you guessed wrong, your Blood Pressure is a little up, let me see you fist thing monday morning and get this checked again and make sure its not a problem. 3 00 in the morning with a pl e platelet level low and baby in stress, all kinds of bad things happening you guessed wrong. How great is it this day and age someone can have a Blood Pressure cuff, record it on their iphone, email it to their doctor and that monitoring can occur in an out of hospital event and people can go on about their business. You significantly reduce undernecessary hospitalizations. Important to me as a physician who practice defensive medicine you also can significantly reduce the unfortunate sequel lie if you incorrectly assess n incorrectly at the time of that event. The development of the savings account, put the patient back in charge and the iphone or handheld device gives the person the opportunity to participate in the monitoring of their affair. It is something that will change the future of compare. Certainly, it would if i were still in practice i would be incorporating those activities on an ongoing basis. As i mentioned, my smart watch wont communicate with my smartphone about the ekg because theyre not available in my country. One of the other tasks if replacing the ing thing the aff act was not enough for the subcommittee im chairing now this term in congress we have the user fee agreements that are expiring. American enterprise are inter t interested what happens at the fda because ive heard from some of you. Im interested as well. We just went through a big legislative effort for the 21st century and there will be ongoing work done on the regulatory side in the user fee authorizati authorizations. This happened in 2012, a tough year to get a bipartisan agreement and we did and the bill got signed into law three months later. You dont know that because the president signed it in a broom closet. It was three weeks before the election. He didnt want to be seen with us and we didnt want to be seen with him, that got done ahead of schedule. The same thing will happen this year, what ever time with the Affordable Care act is being marked up in the secretary of health and energy and commerce and ways and means and happening on the food drug authorization. Thats critical work. The aca reform is something that will happen right now and fda reform are things that happen years into the future. I know that because of when we did our last one, it was very rare that a week went by that there was not someone in my office with a tale of woe how they had difficulty dealing with getting things through the fda. We need to make that a more straightforward. Im not saying anything needs to be shortened or curtailed but we need to make it more straightforward and the agency cannot change the rules late in the game and send everyone back to the starting gate and say we decided on a different set of parameters that have to be shown for this and you have to start all over again. Let me in the next couple of minutes talk to you more from the my role as a member of congress being on the subcommittee doing a lot of this work on the Affordable Care act. Three big pieces of Health Policy have happened in my brief tenure in congress which started in january of 2003. 2003, you may recall, was the year medicare modernization act, bill thomas chairman of the ways and means actually worked very closely with counterparts in the senate. Senator ted kennedy was involved with that and ultimately came up with the part what is now known as part b, Prescription Drug benefit in medicare. President bush, when he was running, said i will get this done so there is no question whether or not it would be done and it got done. Arguably bipartisan although certainly there are people on the democratic side of the subcommittee say it wasnt really bipartisan, you held the vote open for 4 1 2, five hours. That may be true but we were just waiting for david woo to vote and when he did it was over pretty quickly. There were tough spots. January 26th, the date it all began. Phones were ringing because people were having problems. I would argue because it was bipartisan, because both president bush and senator kennedy were interested in this thing working right, you had secretary mike leavitt at the department of health human services. Those were interested in fixing those problems and those questions were quickly worked on and by the end of valentines day, they were old news or ancient history. The Affordable Care act passed in 2009 and 2010. The Affordable Care act was a single party in charge of that. So when trouble occurs, do i want to step up and help . No. My fingerprints arent on that. Why would i get involved at this point . So the lack of bipartisanship, if you will, i think, was dam e damaging on the when the Affordable Care act got into trouble with the implementation, it was not just distracting, it was damaging for the future of the law. Then, in april of 2015 we passed a bill called the medical access and chip reauthorization act. I like to call it the sgr repeal because it solved a problem although created by congress, it solved a problem that had bedevilled doctors, patients and policymakers for 49 years. It took 17 years. It took us 13 years to solve it, which we did. That vote was strongly bipartisan. 3. Aye votes in the house and 92 yes votes in the senate. 392 aye votes. It scared everyone to death. What are you doing to small practi practices, will people be able to continue in a one or two person practice because of some of the things that have come out in the cms rule interpretation. A valid question. Because of the bipartisan nature of that bill when it passed the administrator of Medicaid Services heard from republicans and house members and it was changed and was vastly different. A lot of flexibility was built into that process. Ill go one step further, andrew said he will leave the Comment Period open on comments coming in on the macro rule that was published in october. Thats exactly the oversight you want. Even with all the other stuff happening this year and next we will continue to have oversight hearings on the implementation because it is so important it be done right. Obviously, there will be changes at the agency that may affect for better or worse how things happen on the implementation side. Regardless whos the head of that agency i want them to know the Sub Committee still feels very strongly the legislative language that was passed is what we want to see enacted and dont want to see someone going off in a different direction than what congressional intent was when they received the strong bipartisan majority. The lesson Going Forward i tried to make to the members of the rules committee both as witnesses and committee. The lesson Going Forward for us is we have a job to do for the american people. Not a republican or democrat. It needs to be done by both s e sides, both houses working together, yes, we need to listen to what the white house has to say and ultimately the president will or will not sign the product we deliver to them. It does require all hands to be on deck. Its difficult because right now the landscape is difficult. The well has been poisoned by so many people and so many different flavors its hard to know who went first and who drank first, we have to get over that and people are counting on us to get this right. My focus goes for the patient and i hear from Hospital Executives and i promise you i hear from doctors and people in industry making investments in either medicines, devices, technolo technologies, i want them to do that and thats what the 21st century is all about. We want to facilitate that activity. Dr. Santos has joined me on stage which i know is my cue. The speakers agenda was unveiled last year and the better way is the road map, those are the Building Blocks from the policy the subcommittee is going to take up. I want to point out and i will leave this book for dr. An toto this is the book i wrote after the Affordable Care act passed, i would point out before there was a better way there was a doctor in the house, many of the things talked about in chapter 12 are in fact those policies you see as a better way. Dr. Antos, i give you this as part of your historical reference. Thank you very much. [ applause ] dr. Burgess graciously agreed to answer a few questions. While youre getting yourself organized, let me suggest you identify yourself make your statement in the form of a question, that means raise your voice at the end of whatever statement you will make. Do we have a question. Dr. Burgess. Wait for the microphone. Dr. Burgess, you mentioned the importance of the latest Health Reform effort being bipartisan. To what whats the process for engaging your friends on the democratic side, both the house and senate, to achieve bipartisan reform and what do you think bipartisan replacement of the aca looks like . It starts with listening to people who have good ideas. I would use the Food Drug Administration Safety Improvement act of 2012 as an example especially when we got to repealing the Sustainable Growth rate formula, it was that same template. Allow people in the room. When we said we would repeal the sgr, everybody wants to repeal the sgr but it hadnt been done. Folks on the democratic side were suspicious of us. What are you going to try to pull on us at the last minute . They suggested we get together and do a white paper. We suggested no, enough energy had already gone into this and we needed to write legislative language and counsel would be in the room with us. And people from outside from patient groups could provide their input. The hearings that went on tried to not be slanted towards one particular philosophy than the other. We sometimes cant help ourselves on that, as you know. It did try to be an inclusive process. Is that still possible today at the level of naulgs healthcare policy . I dont know. In fact, one of the things i would point out is i feel very strongly on the issue of medicaid, block grants and capital allotments. Its an ideas whose idea has come. I spent the better part of december saying you guys griped about washington being too much in your business and onerous and you wanted block grants. Be sure youre ready. You may get that back. I would like to see that happen. I do think i generally dont favor things that require a larger government to administer because, as you know, we have a government so big it seems absolutely insensitive to the needs of average americans. I look at it to what will pear down the size of government without being terribly disruptive unless we need be terribly disruptive and i realize we have different philosophies on that and my task as chairman of that subcommittee is to be open and receptive to those ideas. Well have our fights and all night markups and week end m k markups but thats appropriate. Thats what we need to do. Wait for the microphone. Hi, bill signal with the carmen group. One of the things in your jurisdiction is obviously medicaid. You talked about block granting. I think you have seen some letters from governors there is concern about Medicaid Expansion and keeping that going. Senator cassidy and nominee for hhs, mr. Price, dr. Price, have talked about having an option where states can opt to keep expansion, Medicaid Expansion under the aca if they wanted to do that. Is that something you would consider . Yes. Youre inclined to do it . My state did not expand medicaid. I received a letter from my governor just yesterday the majority leader, kevin mccarthy, had sent letters to the governor, give us your ideas, i think is a good thing and Governor Abbott copied me on his letter saying the block grant approach is something they would like to see. I guess part of your question, at least in my mind, what is the pool of money that will form the block grant . Does it need to be more equal between states and means a state expanded obviously drawing down and more medicaid dollars than a state that didnt expand using its legacy or historic map amount, i dont know the answer to that question. I rather expect we will have a lot of input from a lot of folks on this. I didnt mention it before the end of this fiscal year we will have the funding for the state childrens Health Insurance plan in our laps. Is this something we can incorporate into what ever happens next or is it something that will have to be done individually and we talk about whether we go the per capita cap block grant or some other more flexible model. I dont know the answer to that. The reason my answer to your question was yesy theres obviously a willingness to listen to those ideas. 7 00 wednesday mornings for the past several years, i have positioned myself in the corner table at the Capitol Hill Club on the republican side to listen to any republican doctor who wanted to come in and grib at me about anything. The reason i did that, senator cassidy, when he was a house member, was always coming up to me, heres 14 great ideas i have about ideas i want to do. I said, i will give you one hour every week. Dr. Price eventually joined us at that group. I know dr. Cassidy has ideas and good ideas, sure, theres a willingness to listen. Someone back there. Dr. Burgess, paul held mann from held mann simpson partners. A followup to the previous question, correct me if i am wrong but i think a better way keeps the Medicaid Expansion but phases down the federal match. My first question to you, do you at least anticipate the federal match to those states that expanded being reduced based on the house proposal and then you talked about really wanting to pare the governments healthcare role in other areas. As you know the president elect the other day opened his press conference saying he wanted the government to be involved in some bidding process on drug prices. Im wondering what that means to you and how you would address the issue that he raised. The two part question tell me the first part again . The first part is on the Medicaid Expansion. A better way you talked about reducing the federal i dont know the answer to your question. I expect the answer to your question is, yes, followed by an if. I think the larger place where that discussion is going to be front and center, were bumping up against a statutory debt limit at some point in the near future when the new head of office of budget, Nick Mulvaney s says, we are out of borrowing authority. I think at that point with this administration with that o b director, it is likely were looking at places for savings. That 100 f map or 90 part of f map part of the expansion may well be one of the things on the table. I dont know that for a fact. Ive long suspected that is where that anxiety is going to play out. On the issue of drug pricing, i understand there is a significant difference between deraprin and savolty. Deraprin the antibiotic thats been around since the earth cooled the first time, should be dirt cheap, was dirt cheap until somehow i believe the regulatory agencies participated in this, somehow we created a supply chain problem someone decided to manipulate. On the other hand, you have suvalty. It is not just a treatment for management of hepatitis c, its a cure for hepatitis c. A little perspective, when i was a resident at Parkland Hospital in the 1970s, we knew we had hepatitis a and b and theres this other. Not hepatitis a or b . Someone figured out we need to call this nonb hepatitis. Why dont we call it hepatitis c. This is a new disease that went through the blur row and may be a boomer bureau and may be a new disease, you see it advertised. Sevaldi is a cure for that. In my professional lifetime we didnt know it was in existence and then it was named and no treatment for many years. Now, theres a cure but its expensive. But a liver transplant is expensive but death is permanent and i want the cure to be there. I dont want anything to stop the next cure from occurring. I know when we make policy, derapin, thats a real problem and may be on our supply chain side and look at problems we have done as federal regulators and legstors have done that allow for Something Like that to exist. I will tell you i dont think theres any secret the cost of medications over the last three or four years has significantly increased. Im not exactly sure why or that i know all the reasons why. The president elect provided a different perspective on that. Im sure you have all read the part art of the deal, i know i d t dusted mine off and read it during the summer. The chapter where he talks about the skating rink in new york and this was a 6 or 8 year problem, millions of dollars into it and never fixed, he can see it from his Apartment Building and bo bothers him this public skating rink is not functional. He and the mayor get into a hair pulling contest in the papers about it, eventually, youre so smart, fix it, and he did in a very short period of time. One of the statements made by the mayor after it was all over, he has the about the rest of us dont have, he gets the best people to work on it and they know if they screw up theyll never work for donald trump again. Well, maybe thats a fill sof stick approach may be overdue in our large overburdened government. The fact he brings a fresh perspective, i would say i appreciate that. I dont want us to harm innovation, and federal price controls dont work in other places theyve been tried. On the other hand, theres a problem and he wants to see it fixed. I appreciate that. Dr. Burgess, we have probably one minute. Let me ask you a one minute question, its an easy one. Great. When do you expect to see a replace bill . You know the moving parts of the replace bill was the press conference the speaker had here at aei. I dont remember what month it was, it was warm outside, the better way agenda. Theres not i dont think theres going to be any surprise. All of the parts in the replace bill that come through the subcommittee i think are available to you in that better way agenda. Probably too many ideas and probably cant all be incorporated in whatever happens in the next weeks and months. I will tell you this from my perspective and not as chairnl of the subcommittee or member of the Congress Committee or member of the republican congress, i favor smaller bills over bigger bills. The fact that we have a list of things that can be used to fix the problems in the marketplace in delivery of healthcare, i think thats good. Let us evaluate those and perhaps rank in order and start with the most important and work our way down and get as much done in the time frame allot to us. When i did my town halls after the Affordable Care act was unveiled, people were frightened of this 2700 page bill that they saw in front of them, i dont think i had any on the right or left say wed really rather see a 2700 page republican bill. That was never part of the equation. They either didnt want the interference or there were things they wanted fixed werent being fixed. Were on a rescue mission, i say lets fix the things we can fix. Thank you very much and please everyone join me in th k thanking dr. Burgess. That was terrific. If the first panel could come up to the stage. Thank you. Thank you, alice. Good morning and welcome to the first panel. Delighted to be here. I had naively thought that i was escaping the current politics and we were going to talk this morning more about the private certifica sector and the real delivery of healthcare and less about politics but you cant escape. But i applaud the congressman and chairman for his emphasis on bipartisanship and hope that this happens soon. The demonizing and fingerpointing stops and we get again bipartisan cooperation on what to do next. But whatever happens in the Affordable Care act, the private sector still delivers most healthcare and pays for most healthcare in the United States. At this moment, we have a chance to hear from people who are major purchasers of healthcare, what they have learned from being purchasers about how to do this more efficiently and effectively. On our panel, we have some really Big Companies with deep commitment to excellent healthcare for their employees but strong incentives not to waste the companys money. We will hear from some very huge organizations. The organizers of this panel werent thinking small. Wells fargo is one of the largest banks in americay second or third, depending how you count. Walmart is the largest retailer, indeed by revenue, the Biggest Company in the world, with 2 million employees. Well hear from the boeing company, a major player in World Aviation building very large planes and employing a lot of people. We will hear about the experience of calipers, which representing the employees of the sixth largest country in the world, the state of california. I stress bigness because the people on this panel have a lot of market power, theyre depl deploying large resources and have opportunities for significant innovation and have serious incentives to get it right. So were going to ask them to tell us something about what they have learned that might be transferable to other purchasers of healthcare and also what some of their problems have been. Well have time for interaction among the group and questions from the audience. You have in your materials their bios in detail. You will realize what a wealth of experience in Employee Benefits we are drawing on today. These folks know what theyre talking about. We will start with ellie dye of wells fargo. Ellie is a Senior Vice President of Corporate Benefits for wells. Shes going to focus on some of their experience with Health Savings accounts and protective care. Well move to a partner in avenue solutions, healthcare policy and legislative strategy and Communications Consulting company. He has a wealth of experience in washington and but she represents calpers in washington and shell talk about their experience. Then we turn to Sally Wellborn from walmart. She is responsible for Global Benefits from this huge company and has experience in retirement and Health Benefits in several Large Companies and she will focus on bundled payments. Finally, jeff white of the boeing company, jeff is the director of healthcare strategy and policy at boeing. Hes a lead negotiate with boeings aco and he will focus on contracting with contracting with providers and their aco experience. With that, let me start with ellie and well move from there. Thank you, alice and thank you all for being here today. There are so many different levers we as employers utilize to be able to influence healthcare at our organizations. Were all going to touch on different ones as alice has introduced. I will talk about how we have really focused on consumerism, how we focus on helping our team members maybe better decisions around their heart attack and specifically how we do that their healthcare and how we do that about Health Savings accounts. We are one of americas largest private employers and offer Health Insurance to 99 of our team members. To all our parttime and full time team members. We offer Heath Benefits to about 515,000 americans between our team members and their families. This is a big investment for us. Its several billion dollars a year. Within that we cover about 75 of the healthcare premiums for our team members. This focus is because we really want our team members to be their best, whether thats at home or work or communities. To be able to do that you really need to have your health as a key enabler. When we think about our approach to our benefits and specifically to healthcare, we really think about that as being a shared responsibility between us and the employer and our team members. For our team members, its really about how do they make their best choices and spend their healthcare dollars and keep their expenses low smechlt for us as the employers, we need to make sure we put a system in place that has the right structures and tools and education that allow them to have that information to make those good choices. Weve really designed our health plans around optimizing a really diverse workforce. We have 274,000 team members and they span every aspect regarding aspects of healthcare, different coverage, different risk profiles, we have different income levels in our company. We have focused designing our plans giving our team members choice that will work for them. We have three different accountbased plans. One Health Reimbursement account, its a gold level account. That plan is really designed to offer additional protections for people looking for that higher Risk Protection for folks who may be in those lower income levels. Then we offer two Health Savings account based plans. One is a gold level and one is a silver level plan. Those are the ones i will spend most of my time talking about today. With this focus, weve really been able to drive some very good outcomes for our company and for our team members. First of all, weve been able to maintain being able to provide very competitive plans at the same time, continuing to add coverage. These are not bare bones plans at all. These are gold and silver plans. Weve also been able to add coverage for things like bariatric surgery, transgender reassignment, autism programs over time so were continuing to add to that coverage. Weve also been able, over the last six years, to keep our growth and Health Spending lower than the national average, because as we all know, healthcare costs continue to go up and we need to make sure we are continuing underneath that trend and weve been able to do that. Specifically focused in on our team members over the last six years weve been able to keep their average growth and prem m premiums to 1 over those last 6 years on and annual basis. Were really proud of that being able to keep healthcare very affordable for our team members. So im going to focus primarily on the hsas today, since that was the request for our focus in focus ing on consumerism. Just a quick refresher, i know most of the people in this room are familiar with hsas. Hsa is an account an individual can put aside money on a taxfree basis, they put aside their own dollars but also employees can put dollars employers can put dollars aside for them as well to be used for now or in the future. Theyre portable and people can keep them with them and theyre also owned by that individual. Thats a key distinction with that hsa. We really like this model. The reason why we offer two different hsa accounts because we like to think of it as that longterm way of financing healthcare for those people who choose it. If you think about it as that complement longer term for people who want to complement their medicare, similar to how the 401 k has really become that complement to social security, and really be able to think about how are you going to finance healthcare over time . People are really attracted to of our team members are using that hra model and we have 40 plgt of our team members who choosing one of hsa. Here is thing with hsa which we think is important. In order to have an hsa you have to have paired with High Deductible Health plan. We want to be careful about that. They caring deductible. Thats where the shared responsibility for us an employer comes in. We need to surround that hsa with those tools for success for team member to make sure they have what they need to make those good consumer based decision. How do we do that at wells fargo . We have a well being program that allows each team member to earn 800 a year that we place into that hsa account. In addition their spouse can earn up to 800 a year to put into that hsa account. They can use that towards that you are out of pocket costs. Secondly, we need to make sure that we let our team members now how much they are going to pay for services. And give them that transparency into the costs of health care. Thats been hard to do in this country but theres been Great Strides in that in the last few years. So we offer a traens tool so the team members are getting a procedures done or going to get lab work done, they can see easily, if they go to facility a. Versus facility b whats the cost going to be. We have seen great variation for similar procedures being done. Our team members can see that make decision for themselves how much they want to pay for that similar care. We need to make team members have a lot of choice in why he get care and understand the price points for that. If im not feeling well today and i wap to see primary care doctor or walk into Retail Clinic or go to urge gent care or sit on the couch at home and use mobile device see a doctor, i want to make sure we offer all of those choice to our team members to allow them to make those decision. Those are all parts that we invest in to make sure those are available so we can have the choices available. So the key point that i have like to you take away offering hsa is a choice, we need to surround it with that infrastructure to allowed fou good decision. What we have seen in our experience, we have seen the usage double in the last six years. And our team members are contributing to their hsa. In addition to the money we tribute as well wells fargo through the wellness account, 70 are putting their own money into the hsa. That amount has steadily growing over the years. Secondly, really important point their care has continued any time you use a High Deductible Health care plan. When people avowed getting the care they need. We have done a lot of study and dug into our data to soo what the behavior hour in this pace is. What we found is that our team members who unitize hsa get more Preventive Care than those who do not use it. They are getting far more preventative screening. Lower prescription usage and overall loaf lower costs. We are seeing behavior in this space through use of better consumerism. We are seeing the team members who youthize one is there earning well being dollars, second they are engaging in lifelong habit of getting scening of doing positive activity and doing the things that are going to lead them to plan maintain Health Status or make it better overtime. Thats been our experience with using hsa. Theres a lot of conversation about additional ways of improving those. And perhaps well get to some of that as we go get to the question and answer section. Thank you. Yvette. Thank you, dive in. Im happy to be here. Representing calpers. For those of you not familiar with calpers they are largest federal purchaser in the country. They spent 8 billion on behalf of 1. 5 retired workers in their family. They have a similar cost patterns to the National Trends about 67 of costs are encured by 8. 5 of the members. 1 in 4 members have 50 totally spend. Given that case mix and level of spending calpers has have goal of reducing Health Care Cost growth. To support that growth has been leading innovator purchasing innovations that have demonstrated Cost Reduction and improved access in quality for our members. They have developed several highly successful benefit initiative to lay groundwork for different reform incluing some of the panels including bunled payments val based purchasing, intensive Case Management and incentive for disease management. These are no cuffed on insurers and provideders calpers close to implement form not as a substitute for sure but as complement to the initiative. Reference pricing for me have been joint replacement which is one of calpers wellknown initiative has helped reduce our costs without Quality Satisfaction addressing the dramatic cost variation we see in hospitals. Which various quality outcome different. So just to level set referencing ann boyian who used to run crisis, in reference pricing, limit on what it would contribute towards payment proceed while assuring access for all the patients. Its median or some midpoint of distribution in that market. Consumer who select provider gets standard coverage select provider in access of that limit pace excess amount. That excess payment made by the consumer does not count toward limit. These are net works exclusion but a milder form benefit designs. Pricing offer partial provider where as offer full coverage and no covering at other provideers. How did calpers go about this. In 2011 selffunded ppo plan which as 220,000 subscribed priors. Threshold for 30,000 hip joint replace m the. Hospital stays. Designate hospital access of that threshold the member pace the different between the charges. Anthems assure ad quit access and Member Distribution and geographic factors. Complied with the payment threshold and high quality facilities in california, university of california, cedar sigh nigh, in 2012, colon scope price on the services from about a thousand to 6,500 for cat rack removal from 1250 to 1505 a little different. Its member goes a member can go to am laory center or receive 2,000 for cat rack, 1,500 for colon scope performed in hospital out patient setting. In 2013, the average calpers price was about 7,500 and afc was about 25. A colon scope was 2,500 and asu was about 1,400. The results have we shown. Our results show increase use facilities had good or better clinical quality patient sperps. Decline 26 over 9,000 per procedures. The hip and knee program in total cam laive savings over two years. Cat rack and colon scope Surgical Centers from 72 to 95 . Declined 16 . Average colon scope in total cat rack program is credit savings of 1. 3 millionment. For knee and price fell about 17 . These are actual Price Reductions not a slowdown in the rate in price growth. Theres a different in how it was achieved. For hip and knee replacement, they expand procedures from 72 in 2015. For cater rack thats a consume r spoir in the increase use in lower cost. Hopd didnt change but the savings afc. There are significant policy considerations that come with initiatives like this. Programs have a number of consumer programs built in. In our Program People have option of where to get the care and are able to get their care locally. We did and calpers provides exception when member live 50 miles from service that offer before the limit price. For using high price facility or setting. Another policy setting, done with shopble proerds. Knee replacement surgery are elective. He can decide whether the proceed can occur. Hospital procedures, 40 of health care for services which patient could shop for. Policy develops have to be watched out of pocket limits do not allow for reasonable consumer ensennive with the company protective are put into place. Reference pricing requires patient to have easy access to quality data. A level of transparency which is not yet commonplace. What ap kantble. Members. For a nationwide em employer purchaser, you have to identify to maintain access to local care and consollation maybe initial in some areas country. Have you to determine whether the prices are set locally or gnashly et cetera, to undertake reference Pricing Network variation must be allowed within limits for the its difficult to apply this to traditional medicare where those things cannot vary. Medicare maelt plan because they differential cost sharing altogether, could use reference pricing. Medicare has been discussed. For example, the part b demonstration proposed never finalizing, reference can be done under phase two. Similar drugs and set a bench mark pay for all the drugs in that category. It can be amount agency considers most costeffective in the group. So bottom line with adequate consumer protection, and engage consumers whale maintaining quality and Patient Experience but limit takes denlding on the organizations flexibility and scope. Thank you. I hearing one pattern here. Theres lot of things that work but it maybe hard to apply universally thats difficulty. Sally, tell us about walmart. Thanks for sponsoring this opportunity to share what some a fuel employers are doing within our own health plans. Its interesting because i think you referenced market power due to our sighs im not sewer we agree that we possess market power even though we are as big as we are. You buy a lot of stuff. Its distributed and there are a lot of Market Forces we are dealing with. So walmart, as alice said we do have a lot of associates with our employees. We have about 1. 2 Million People for whom we provide Health Insurance within the United States. Outside of the ouds. So were bigger than many health plans but were distributed into every zip code within the United States which is a challenge. As we look across our entire population we do and have used a number of these different mechanism that well talk about on the panel. What i want to share is about what we did with bundle prizing related to centers of excellence. Our drivers were not really about the cost of health care or how we pay for health care. We knew that was important. But driver is around the quality of the care thats provided to our associates. Theres a wide variation in both cost and quality across United States. We know that we had pashlgts going to provideers not getting the highest quality. We wanted to ensure other associate and family members knew where to go to get that quality. We focused on centers of intelligencexcell theres little dispute about what the protocol should be the evidence based medicine should be for certain cardiac car and spine procedures. We went ba about finding a handsful of facility top tier high quality, but wanted to have a small number that were geographically dispursed that would meet our limits. As we were developing it, we determined that we wanted to ensure we had a line incentive between the facilities providing the care and walmart. So we were april lined and the primary focus is quality and not just delivering care. So what we did was create a bundle and its a pros speckive bundle because its differentiate between the way bundles are created and created today within medicare, many other Company Create retro speckive bunld l after the fact you determine what the cost should have been. We work diligently with the centers that we identify when we set this is the amount that were going to pay for the care and then went on to define what the amount of the care what the kinds of care that could be include in the bundle of the two things. First of all, that amount that we negotiated was not very different than the amount we would have paid on a traditional see for service this whats not about negotiates a price that was a low price. This was about creating a scenario for the provider that would say, look, were going to say were going to pay this amount. You determine all the care that needs to be delivered within that bundle whatever it is. Were not going to dictate what the care is. Were not going to limit you or encourage you to provide care. They have requirements of delivering outcome that are high quality outcome. We wanted to make sure they deliver high quality outcomes. These bundles are, they include the preop, the surgery, postop and return home. So beginning and ends defined. There are two bundles. Theres the original, the first bundle thats assessment bunned thats where the associate who has 100 coverage if they have procedures needed, their the procedures is covered 100 . In addition all of travel is paid for for themselves and someone to go with them for whatever period of time you go to that facility. To go to the facility in a team of clinicians work with the patient to assess the situation regarding their need for surgery. The teamworks with the patient through shared decisionmaking, through conversations with physician who are specialist in our area of expertise and make at the significance among the team about whether or not surgery is indicated. The team inclauds nursing advocate it includes facility, all the of the people that would be involved with discharge plan. Theres entire Team Integrated across the facility. They make assessment about whether or not the proceed is necessary, they work with the patient, if they decide surgery is not necessarily, the pargt they give the patient what the patient didnt go because they felt good, they went there because they have a issue. They help the patient figure out how to solve the issue but it may not be surgery through the facility. The bundle does not encourage the facility to provide surgery. But maybe at the significance for the patient. If theres a decision, the cost is covered. If the patient comes in with a lot of mo morbidity, tracking of course the outcomes they are really great outcomes. The patients are coming back saying they could not have a better experience. They ask question why isnt Health Care Like in this my neighbor which is painful for us to hear. But we are its interesting because the facilities that are working on in this arena for us talked to one another through structured conversation and shared best practices. How you treating this patient that comes to with set of criteria. What are you learning about this. Theres an elevation of all of the centers of excellence about treating the patients. We actually were surprised, pleasantly surprised at the number of people who determined that they did not need surgery. Its happening different we started with expand into ber ray at trick surgery or cancer or center for excellence for the treatment of the cancer. The surprising thipg to us is the number of pashltient that g the center and discover they dont need surgery. Thats happening in every one of these areas of expertise. And in the cancer area, its shocking how many times the patient goes the center of excellence and determined they have been misdiagnosed or the treatment is the wrong treatment. Cancer treatments are we know cancer is difficult. Figuring out the right treatment is job most important thing of so the savings that were experiences are not about the fact we have floerkted a bundle or that care is being not given because we Incentive Center not to deliver the right care, its because we are determining that harmful care my have been delivered to the patient and were avoiding that harmful care. Thats our experience in bundle. The first was the assessment bundle. Correct. Then the treatment bundle. Yes, two separate. Good. Okay. Joe. Good morning, thank you for hosting this morning. Im going to focus on the care we have been doing boeing with the provider community. This is born from frustration that a lot of employers feel about the high cost of health care we spend. We spend 2 1 2 billion a year. Pocket where we do have a high concentration of employees. It was a frustration with not only the line item of Health Care Experience but the trend we br experiencing. We need to solve for that. Its not stainable over the longterm. We had worked a lot of the demand side strategies asking the employees to pick up the tab. We believe in the consumer affect of the hsa is a great strategy. We want to take more of a step stoords directly with the supply side of things to move ourselves into that space in a more meaningful way to drive accountability and value in what we were paying. Sallys kplecomment about the quality. We moved into space traditional employers tract with Insurance Company to network. We decided to go to the provider system. We could go to the table with a clear understanding of boeings population. We underthe investment will pay diffidented 4 or 5 years from now. Whether we talk about Hospital Systems taking risk, it was easy to have a conversation about risk than you can with an Insurance Company. Why we went directly to put contracts in place. We have five of them around the country that have live now. Different than medicare aco, people go to annual process elect to be in aco they know they are in a different program. The setup the contract on three principals. Improving experience, equal, and value we get. From a quality perspective, we introduced 15 nqfs we want to put a hundred in the contract its a wide spectrum that we measure and hold the systems accountable for. Things like having a 1800 triage number to navigate the system. Dedicated website giving employees access to Electronic Medical records. A lot of that was happening, i think we moved the needle on how quickly that was happening. The relevant meat of the conversation was around until we do that, were going to be stuck in fee first system where you pay for not for quality. At the surface its simple. We incentivize our employees to elect ppo. They get 95 plus maybe more. That would drive volume to the hospital system. In return they guarantee intake risk and financial trend for us overtime. If they meet we share the savings back with the system. The systems are we have five of them. I think we will see Different Levels of performance. We will be cutting a check for some of them for performance. We want pay them back. Thats what we are pushing for. So its great to have a contract that aligns assentives. They have to figure out how to deliver care in a more efish yent ya way. How to deliver care more efficiently. We have to pay for Spine Surgery if its not necessary. We dont want to pay for thats thats a little conundrum for them. Because its a revenue generator for them. They need to make sure they installing right clinical pathway before we do expensive surgeries like that. Prescription drug thats easy to see how to manage that better. We would not expect systems to understand boeing versus another s system. We give them almost realtime Prescription Drug data as part of the arrangement to understand which are outlier in their prescribing pattern. They should be able to manage the patient better. All the doctors interfacing with that is operating off the same system. Thats a big thing. They making steps towards lets introduce quality come come peization. Its try to meet the financial challenges. In terms of results were very pleased with the Quality Improvement that we have seen. Our members really like it it. We have done some focus groups and they rate the aco 8 or 9 out of 10, the employees like the service they are getting. Of course we want them to meet their financial targets, we are excited about what we see them do in specific pockets. Imgive you an example, e consult, if they are unsure, theres a another four hours away interest the office or production line, if the primary physician can do e consult without having to send the employee back, but the productive is hugely important to us. Cool things like that. Behavioral health, you take a place Like Washington where we have lot of managed care, Behavioral Health was not talked about. The physician were not good at addressing the Mental Health needs and the data is clear. Depression is morbid with every other condition and needs to be address. Theres no reem burrsment mechanism for that. I would not blame them for not addressing that in a more meaningful way. They know they are financially responsible for these folks over the long time. They see value of reinvesting in that. We are excited to see bigger changes like that figuring out Behavioral Health. I have see psychiatrist is triaging a patient, its stuff like that that were opt misic this will enact some change by forcing accountability to them. I think this is a multity stakeholder issue that the country is facing we need em employers, policy makers, Insurance Company and provider voiceamerica s to figure out a way to come together. One think you mentioned was that they the employees have to elect to be the aco. But if you have to elect to be in it, that gives you an opportunity since you know youre there, to engage the patient in their care. And maybe to do some of the things that elly was talking about of getting the patient earning some points to by doing things that are good for their health. Is any of that happening . Yes, thats an important aspect of it. We dont go as as far as as requiring them toll select a primary care physician. We encourage them to. We believe in engaging them with a primary care physician, if they dont select one, we try to reach out to them. Generally speaking they expect to have a different level of care throughout year when in an aco. We are setting them up. We can be even more agreggive in terming trying to be a little more we want this to be viewed as an incentive as this time. Others could be more aggressive in their requirements. The aco itself could be. Lets open opportunity for the members of the panel to question each other. Or it does seem to me there maybe some things that you talked about that could be picked up by others. Did i hear you say you incentivize them to join. We do. Its 350 a year over a family. Theres a Strong Financial ensennive for the em please to consider joining the nco. Its negotiates. Did you look at the penalizing them for not joining them or we did not. We have an employee relationship where we want to be incentive always. You could do that if youre in a particular situation. But not for boeing. I want to ask about outcomes measurement. Because everybody mentioned it but the hidden agenda is were not there yet. Its lard to measure outcomes. Do any of you have comments on progress that you have made on measuring uk or the difficulties. We have been live with some of these for a couple of years, we are little early in providing statisticsly outcomes some of the challenges we face in measure the appropriate way theres a selection bias healthier people select the aco so we have to solve for that and make sure we have enough data to measure the outcomes. We are encounseling with the relationship with have in what we see in the integrating system doing. Its too early for that yet. In our program is such a limited population that we do have outcomes what they had done in the centers of excellence. Yes, center for excellence. The patient reported outcomes are good. I think measuring the distan difference between what you paid what you could have paid. Its quality measures that are hard. Right, i think those are hard in every purchasing initiative. Those are just what needs the more work. I think. We are focused on that ultimate indicator of the health risk of our employees. There are a lot of indicators of that usage and condition specific progress, we do a lot of work in looking at whats working, who earning wellness hours, engaging in activities but the end game is are people staying stable or are they improving in that health risk status. What about earning the wellness dollars, are you studying how the wellness relates to what they do . We do look for correlation there as well. Theres a positive correlation. Have you found anything startling like if you only ate your breakfast you would be much healthy or. No its not quite as simple. We have helping people earn their dollars. We have 60 who earn that well care dollars. So were talking earlier today about the advent of the iphone and other device to make things easier we up gaited our platform so you can do the activities right in the palm of your hands. We have different population, represented here. At least this is researched this, but i suspect jeff, youre population is high skilled and high paid and sallys is low skilled and lower paid. I wonder particularly you talk about the centers of excellence which is a small piece how is your Health Care Deliver affected by the by you have large number of low income people . So it is really important to us to be able to offer plans that are affordable to our associates. So our plans are less than 20 every two weeks for silver levels kinds of plans. They are not bronze plans, these are nice coverage plans. Affordability is primary for us for our associates. The only way we are able to provided affordability for them is provided highest quality and eliminate inappropriate care and have them have access to the best provider. So we focus from that perspective. What we dont have is the luxury of having people the preponderance dont work for us for decades as opposed where some work for them for decades. We have lot of people tla work for us entire career start at hourlily and become ceo, that does happen. We dont look at it from the same standpoint where were investing in five or ten year outcome in their health, what can we do to help with health care told. We are not considering whether its longterm investment or not. We want how can we help today. Yvette, your population is longterm, you could afford to think longterm about their health. And we do. As i mentioned at top, i think our Health Status reflects the National Population with the pop of chronic illsness, bi dont think they ae less health year because they live in california. We track and Development Initiatives that focus on health care longterm. We are not purchasing nationwide and can drive someone from a centers of Excellence Program we have them have a longer term focus which helps with the initiatives. Lets throw it open to the audience to ask questions at this point. I believe there are microphones. Tell us who you are and make the question a real question. Im binder from the lee crop group. My question is with health plans. All the debate in washington about what to co with the Affordable Care act health plan covering i done think men of you mentioned the health plan. How have you worked with health plan. Whats youre role. How we should be thinking about it given your experience with health plans . So i think one of the focus of this panel on this day was about innovation. And what if you look back over the history of innovation in the health care space, leek frag itself is an example where innovation came from the private sector from employers who identify look for a way to solve it. As time goes on the health plans because theres some opportunity identify theres some means they can learn from it and provided on. So were seeing health plans that are learning from the early work that wells fargo did around consumer plans. The health plan really engaged in that bunld l and hsa and nco. And then expand to the health plan, i think that innovation is expanding and it also goes the other way where innovation could happen within cms which it haens when were rather thanning from that as are the health plans. So its is not chicken or egg but its a little bit of both working together. I agree its a share of best practices. As i mentioned we calpers work closely with our plans so the pricing was initialled by Anthem Blue Cross of california. We work with insurered and tracking the outcomes in terms the claims to figure out whats happening to a member. For us, the health point is point to aco but in a different way. They needed to figure out to get data to aco partners in a way they are oe not used to. I would say the health plans are moving towards more value based purchasing. For some smaller employees thats the avenue they would need to go to enact that. I would put them in they will be a key stakeholder in helping us to figure out how to drive more accountability theres no doubt about that. Following up on that, what about how employees choose health plans. You talk about what information does the employee have to make that choice. Thats a great question, because i think Health Care Community is confusing in terms we throw around dont maybellket of sense to someone who different from what we do. So we have decided to invest in some significant decision and tools for the members to utilize during the year and annual enrollment time frame. We use a benefits counsellor. A fund sort of guy, his name is alex, jelly vision that walks people through a situation asking them questions, whats parent to you, whats family situation like, how many prescription do you have, whats your overall goal. Then walk through which plans maybe best and the pros and cons the different plans and explaining that. We use it for owl of our wbenefits. Its an Electronic Exchange with an automatic guy. Yes. So we want to make sure our team members have all of those options. Other questions. Our sara, Health Reform. This a fantastic panel. We have heard about several different tools for better driving decisionmaking by patients and by their Health Care Provider or professionals. I want to ask sally, i was interested in the your mention of the shared decisionmaking tools and the effects of the outcome of the people deciding that maybe he dont need the more treatment. Can you talk more about the how you decided to incorporate that into the bundles, how essential do you think it has been to achieving the outcomes that you achieved i. This is not a tool, this is a meeting between the patient, the family members and a team of clinician, we did not put it into a tool, share decisionmaking this is actual shared decisionmaking where every one is informed with preferences, clinical information, and all that sort of thing. So its just built into the process. And its not a tool. Its truly what if you were not a if you were a light person ask you talked about shared decisionmaking thats how you describe it. All of us in the business say share information no its sharing a decision. That is what you do for a relatively small population apart of your population that is in such serious circumstances that its worth it to the company to take them to the center of excellence. Is there anything comparable with somehow to manage diabetes or its not a tool but for people who have diabetes we do have Diabetes Support Program that engage with health plans and also various programs be able to manage the diabetes in a better way. Having programs to allow you to better interaction about man managing that care. Theres management programs we offer throughout the program. That affects a lot of. Absolutely. Some have multiple conditions. Yes. Wells fargo mirrors United States population. We deal medical you have par patient seeing six physician, having a shared care plan, not a decisions making tool per se but the person using health care in a significant way making sure the health is coordinated a better way with the doctors. Free market monkey blog. I have always felt that the employee pro vision is central to the whole problem. Do you think with jeff lake Health Savings account expansion act that companies would organically define contribution and where it would become common to match a contributions to an hsa as it is to 401 k today and employers would have ownership do you think we would be this a better position . Anybody want to take that one. Okay. So, im not going to predict the future as to whether or not it would be better or worse. I think that the employers i have talked to, our focus is on providing Affordable Quality Health care. And if all of the offerings within exchange or the marketplace were Offering High quality affordable plans, i think it would be some employers would think about arranging their delivery of health care that way. I think that there are employers as you just heard today, theres innovation that happens at the employers side the product payer side that has been valuable to the system with respect to changing the deliver system and encourage positive outcomes. So i think there will be a portion largest portion or smallest portions, i dont know, but i think that innovation that we strife for will continue to exit and even if we move to a different model we will continue to innovate been that model. I done know that. To say everybody going to move into a one felt swoop or everybody is not going to move. Its going to be a split, the early reading is not Many Companies have not made that decision to that point. I have kplecomments for cont shared insensitive. It is in team members to be healthy. So that they can be productive and do the work that we would love for them to do. It is in our countrys best interest for our employees to be healthy because some day they are going to retire from calpers or walmart or wells fargo, so we have this shared interest and so how that happens is impactful on all of us and i think that all of us as employers regardless of what the current structure is or what is legislated from the Health Care Perspective we will a lot of provisions that under todays legislation are required. Many of those provisions have put in place and have had in place for a long time. I think we will always continue to evaluate what are the structures that are available. For us we override that with that broader objective of we need to provide our employees with an affordable comprehensive Quality Health care. Yes. Thank you. I think health care is very important but is also for consumers or patients or their families mostly ignorant and for some reason they dont know what happened and especially if you think about mentally ill. How are you going to save yourself but also their lifetime savings . This is a very important and very csignificant and very increasing segment of our health care and nobody seems to really have a good all together Society Point of view. Yeah. I think theres various advoca y advocacy. In our particular one we asked them to take on that responsibility and my comments about health needs to be embedded at the primary care level here. That seems to make sense. I think there is a role for advocates helping our employees through the system is very stressful and very complicated. Something needs to be done to help navigate. The population they were aiming at im curious on the other areas you mentioned and sort of more broadly for the panel, you know, as you know a lot of debate in washington is about the individual marketplace and medicaid what are the adjustments that need to be made that youre discussing work in these markets . Can you give me a little more what youre looking for from the hospitalization side . Well, i read there is some concern i dont even know whether there is any [ inaudible ] but just more broadly im wondering if you could provide any hospitalization and also in an area where you saw it in percentage or some other terms what kind of drop you saw or what kind of increase you saw in from ventive services. Yeah. The most significant change we saw with this population was the increase in their engagement with the Preventive Service with going to see their primary care physician. Thats a 20 increase with this population. That, we believe, is the enabler for everything else. If you have that ongoing relationship with your primary care physician then that allows you to say am i on the right drugs . So the drug difference was not as significant of a decrease and a lot of times we find people might be on the wrong drug regimen. You know, when you look at what people are doing. So the drop in hospitalization was really an er usage. You really see a difference in populations. Part of the comparison is when we are looking at our population that uses the Health Reimbursement account versus those of the Health Savings account. This is our account that has the more first dollar protection. So we see those accounts with additional dollars from wells f fargo depending on your income. When you need medical care it is 100 paid using those dollars up to the amount thats in that account. So if somebody chooses to go to the er using one of those accounts it is fully paid versus if somebody goes to the er using a Health Savings account it will have a more Immediate Impact on them in their personal pocketbook. Youll see that difference. I think what we are seeing is if somebody is in an hsa and they are not feeling well they are probably going to stop and think a little bit more to say do i need to go to the er or might i go to urgent care instead . Thatsenerally a positive behavioral change we would see as a good thing. When its coupled by that impro improved relationship. [ inaudible question ] okay. Yes. I think i see a hand back here. So we have a lot of Different Team member groups and choices that people can make with their health care so ill use the example of somebody electing single coverage. So they are able to if youre single coverage and youre if youre in our plan your premium is about 30 per paycheck. Are there other questions . Do you contribute to. [ inaudible question ] we contribute the wellness dollars. We do not in addition contribute to the hsa. We contribute to if they contribute to the hra they would contribute 700. Two questions. The first observation is we are talking about four different initiatives that would appear to have made strong strides towards improving the health care. Very different but all originating from employers. The first question is has there been any effort to look at the impact to quantify the impact of your initiatives on organizational performance or profit blt . The second question is have you seen if you are taking steps that are increasing are you se seeing [ inaudible question ] so two different questions there. I can go first. I think for our specific initiative we are able to quantify what we expect and i assume when you say Organization Financial outcomes for boeing we are able to generally understand what we think this program will yield over time in terms of savings. So we have a good idea of that. It is variable on performance on any given years. We expect to have material savings out of this initiative. I think providers would say they dont treat boeing patients different. So in as much as there are some Delivery System reforms i would think it would be other stake holders that are using that system as well. My hope is that would be the case. If we help them change the way they are doing it it will be transferable. Washington at least pretty quickly followed a similar contract for boeing and improved it with Different Things we liked as well. There are some pathways to doing similar things. I think it would go for all of our examples. I think follow an opportunity for other stake holders. Yeah. I would add obviously every dollar we have goes back to taxpayers. It is important we get the highest return on investment for Health Care Dollars chltd i dont think theres any doubt amo amongst the stake holders has permeated all of the stake holders including our members. That has come, you know, from the federal level, from the federal purchasers, from the employer purchasers and at the state level as well through medica medicaid. I dont have any doubt this sort of permeated and they are changing the way they practice whether it is because of our initiative or boeings initiative. It will move through all of the patients that they see in terms of having a different focus on how they practice and whether it is really a volume driven or value driven. Ill answer the question a little bit differently. I dont know if this is what you were asking, whether there was an r. O. I. So the savings, thats a net savings. The different question is has there been an uplift in any of the Business Metrics such as sales or net revenue or net proffer or whatever. We have studied whether or not our well being initiatives have provided a positive impact on our business. We have been able its actually very difficult to do. There are so many things that would well, the weather was better this month. You know, christmas came earlier or whatever. What we really tried hard to do is something that was very statistically sound and eliminate all of the founders. What we discovered is that in our stores that participated in our Wellness Program to a relatively higher degree there was a positive impact on sales in the stores versus stores for whatever reason the store didnt get engaged in our Wellness Program. So we have done that assessment. That is kind of the you know, from a corporate point of view are we adding back from the company and we did do the study and found that it did add value. It is one of those questions, is wellness really worth it . It really is and improves sales in our scenario. I think we have time for one more question. Right here. I think its a great panel. I think what youre doing about focusing on delivery reform is an important thing to get them to figure out what they need to do, whats the best treatment for them. Thats lot of emphasis on cost. Where do you factor in or do you factor in the need to train the next generation physicians . If youre always looking for cost savings, does that ever factor into it . We talked about that that needs to be done. Whats your responsibility . What is our responsibility . Thats a good question. I would say one angle of that is that we work with our health plans to ensure that all of our payment structures are based on evidence based medicine. So all of the medical directors that we work with are ensuring that our programs are aligned with that and then that goes back into the medical community. That would be the ankle thgle w connected to. I think you raise a good question but its not part of our broader conversation at this point in time. Let me ask a final question of everybody and come back to public policy. Uhhuh. In what way could federal policy, which is very much under scrutiny at the moment, but if you had one or two things that you think ought to happen at the federal level that would make it easier for you and your companies to do what youre trying to do to have good coverage and a Healthy Work Force and savings for your company, what would it be . Well, i would say the one thing that i would encourage anybody, including federal government or local governments is to focus on aligning incentives and providing a competitive marketplace that focuses on the appropriateness and no sharm done to the patient. It sounds lofty but that piece of inappropriate care i think is the one in an open mark. I agree. I think on a broader level medicare is going to react to incentives and quality focus that medicare puts on the table. Because its so big. Yeah. So its helpful for other employers to if medicare helps align providers in the same direction we are trying to align providers. I think the federal governments ability to investigate and try different initiatives whether it be on consumerism or research that informs on what works and what doesnt work that informs the employer and other purchaser communities can be done ton the federal level. So that is an Important Role that needs to happen at the policy level. I would you know, in the context of hsas i would support giving us a little more flexibility in how Preventive Care is defined in being able to you know, today Preventive Care is outside of the deductible. It is helpful. But what it doesnt take into account is Preventive Care for people who have chronic c conditions. Their Preventive Care so that their condition doesnt advance would include things like foot exams and those things. You have to meet the deductible before those are covered at a higher rate. We would like to have flexibility in how that is defined to care for that population. And then the other thing that we would love to see is we have a lot of veterans who work for wells fargo. It is a really important part of our population. Because many of them are covered under tricare or utilized v. A. For care they are not eligible to contribute to an hsa. I dont know that theres one model that would necessarily work in every market or you have different issues with rural and urban settings but driving towards pay for value is critical to the long jifevity oe system. Well, join me in thanking the panel. [ applause ] a nan holds in his mortal hands the power to abliej all forms of human poverty and all forms of human life. Let us take inventory. We are a nation that has a government, not the other way around, and this makes us special among the nations of the earth. And on monday at 8 00 p. M. Eastern on real america the 1977 film the time has come and originally created for overseas audiences. The Film Documents the progress of african americans. The registration, the voting, if it took a patient a bringing about a new sense of hope and not just a new sense of hope and a new sense of optimism. American history tv all weekend every weekend on cspan 3. At the same event hosted by the american enter prize institute td