Transcripts For CSPAN3 Representative Michael Burgess Discusses Health Care Policy 20170123

Burgess of texas talks about efforts to repeal and replace the Affordable Care act. Hosted by the American Enterprise institute, this is two hours. Okay. Okay. I want to thank everyone for attending this event today. Im joe antos, the wilson had h. Taylor scholar for Health Care Retirement policy at the American Enterprise institute. On behalf of aei, the Brookings Institution and the Pacific Business group on health, i want to welcome everyone here and everyone watching remotely including those who are watching cspan to todays conference. Were going to discuss High Quality Health Care that is available for patients, employers and taxpayers. This is a critical topic for government poll he icymaker spo. The recent election highlighted the disagreements among many people in this country about what is the best way for government to proceed in this area. And 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 ensuring that people continue to have access to Health Insurance. Employers have long been at the forefront of this struggle for Affordable Health care. About 150 Million People under the age of 65 are covered by health plans sponsored by employers. The average premium for family coverage offered by employers was over 18,000 last year, 2016. Thats 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 slowed wage growth for millions of americans. As Health Care Costs have increased, they have increased, large employers have invested in Innovative Strategies to promote value and to control costs through patient engagement, provider payment reform, and Delivery System improvement. Were going to discuss some of the initiatives undertaken by four large employers, to deliver more Efficient Health care delivery and better cost. What can we learn from their successes what can we do to help resolve the problems they faced in dealing with cost and quality problems . What is the role of government in 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. To start the discussion we are honored to have dr. Michael burgess, chair of the Health Subcommittee for the house 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. Dr. 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 phenomenal opportunity to 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 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 accounts. Turned out i neednt 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 placed, should it be placed by the government . Should it be a waiting list . Should it be rationing . Or do you want some sensitivity, some market feedback on the part of, yes, the physician, but the patient primarily because the patient is the one who, 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 Savings account. My Health Premium dramatically reduced. If i had the discipline to put some of that money im not 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 yesterday, 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 got a special subsidy that was untaxed that 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. And remember they extended it for 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 night, this guy has no heart, i thought i better assess whether there was in fact electrical activity in the m 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 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 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 platelet level low and baby in distress, 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 unnecessary hospitalizations. Important to me as a physician who practice defensive medicine you also can significantly reduce the unfortunate sequel lie if you incorrectly assess incorrectly at the time of that event. So those two things, the development of the savings account, put the patient back in charge and the iphone or handheld device gives the person the ability to participate in the monitoring of their care. These are two things that i think will profoundly change and affect the future of care, 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 Affordable Care act was not enough for the subcommittee im chairing now this term in congress we have the user fee agreements that are expiring. I know many people at American Enterprise are 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 reauthorizations. 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 2012, he was running for reelection. 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 and Drug Administration reauthorization. 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 and Human Services was interested in it working correctly. There was a lot of effort into fixing those problems. And i was impressed that the problems that started at the first of january were quickly ameliorated by the end of the month or by valentines day they were pretty much 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 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 17 years. It took us 13 years to solve it, which we did. That vote was strongly bipartisan. Strongly bicameral. When the proposed rule came out in june of this year, it scared everyone to death. What are you doing to small 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 subcommittee 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 that vote received that 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 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, technologies they think will be important for the future. I want them to do that. Thats what the 21st century is all about. We want to facilitate that activity. Dr. Antos has joined me on stage which i know is my cue. The speakers agenda was unveiled here earlier last year and the better way is the road map, those are the Building Blocks for the policy that the subcommittee is going to take up. I want to point out and i will leave this book for dr. Antos, 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 ] just stay there. 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 out here . 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 and Drug Administration Safety Improvement act of 2012 as an example, certainly when we got really deep into 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. We also opened up an email source so people from outside, doctors and 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 National Health care 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. Really something it is an idea whose time 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 recognize people have differing philosophies from that. And part of it from my task as a chairman of that subcommittee is to be open and receptive to those ideas. Well have our fights and all night markups and week end markups but thats appropriate. Thats what we need to do. Sir. Again, 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 more federal 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 whatever 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 yes, theres obvious ly 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 gripe 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 things we ought 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 heldman from Heldman 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 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, nona, nonb hepatitis. And someone said why dont we just call it hepatitis c . This is a new disease that went through the nomenclature and it is 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 so ill pay for the cure, no matter what it takes, but 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 legislators have done that allow for Something Like that to exist. I will tell you i dont think theres any secret the cost of generic medications over the last three or four years has significantly increased. Im not exactly sure why or that i know all the reasons why. Ill also say that the the president elect provided a different perspective on that. Im sure you have all read the art of the deal, i know i 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 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 ability 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 fill of soish philosophic approach that 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, not as a chairman of the subcommittee, or member of the Energy Commerce committee or a member of the republican conference, 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. I think the last when i did my town halls after the Affordable Care act was unveiled and people were frightened of this 2700 page bill that they saw in front of them, i dont think i had anyone on the right or the 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 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 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 genuine 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 america, 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 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 elli dai of wells fargo. Elli 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 eve fontenot, a partner in avenue solutions, Health Care Policy and legislative strategy and Communications Consulting company. She has a wealth of experience in washington. But she represents calpers in washington and shell talk about their experience. Then well turn to Sally Welborn 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 negotiator with boeings aco and he will focus on 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 make better decisions around their health care and specifically how we do that by utilizing Health Savings account. 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. So under that 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. And then for us as the employer, 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 around 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 premiums to 1 over those last 6 years on an 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 focusing 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 employers can put dollars aside in those accounts as well to use for health care 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 these. In our company, 50 of our team members are using that hra model and we now have 40 of our team members who are choosing one of our hsas. Heres the thing with an hsa we think is super important. In order to have an hsa, you have to also have it pared with a High Deductible Health plan. We want to be really careful about that, right . Because if somebody has a high deductible, theyre paying for their health care up to that amount of the deductible. So thats where the shared responsibility for us as an employer comes in. We need to surround that hsa with those tools for success for our team members to make sure that they have what they need to make those good, consumer hadbased health decisions. How do we do that at wells fargo . We have a well being program that allows each team member to earn up to 800 a year that we then place into that hsa account. In addition, their spouse or domestic partner can earn up to 800 a year to put into that hsa account. And they can use that towards that you are out of pocket costs. Secondly, we need to make sure we let our team members know how much they will 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 transparency tool so that our team members are getting a procedure done, or going to get some lab work done, they can see easily if they go to facility a versus facility b, what is that cost going to be for them and we have seen great variations between facilities for very similar procedures being done. Procedures down tand now the team members can see it and make the decision for themselves how much they want to pay for the similar care. Finally, we have need to make sure that our team members have a lot of choice of where they get the care and understand the price points for that and if i am not feeling well today and i want to go see my primary care docker or the, or if i want to walk into the Retail Clinic or go to urgent care or simply sit on the couch at home, and use my mobile device for telemedicine to see a doctor, i want to mach sure that we as an employee offer all of the choices to the team members and the price points to allow them to make the decisions. Those are all parts that we as an employer invest in to make sure they are available to make sure that we have the choices available. So that the key point they want you to take away is that offering an hsa is a choice and a really good thing, but we need to surround wit tin fra sfrauk chur to allow for the good decisions. So what we have seen in our experience in this space is that our team members are using the hsa and the usage has doubled an also our team members are contributing and so what we contribute at wells fargo of the wellness accounts, about 70 of the team members are putting their amount into the hsas and it is steadily growing over the last two years. And more importantly, the care is continuing. Any time you use a High Deductible Health care plan, the people will have a concern of going to get the care they need, and so we have done a lot of study here of the team members to see what the care has been in this space, and it sep couraging so that the team members of the hsa will get significantly more Preventative Care, and so they are seeing the doctor, a tland also getting far more preventative screenings. They have lower emergency room usage than those who do not use the hsa lower prescription usage and the overall lower costs, nda so we are seeing the very good behaviors in the space, and through the use of better consumerism. Finally, we are also seeing that the team members who use the hsa are far more engaged in the wellbeing activities and good on two fronts, earning the wellbeing dollars and engage ing in the lifelong Healthy Habits of getting the screenings and doing the positive activities of getting in motion and doing things that are going to lead them to either maintain their positive Health Status or make it better over time. So that has been the experience with using h sx a hsas and as we heard from dr. Burgess, there is conversation of the additional ways to improve those and we will perhaps get to those as we goat the question and answer session. So i turn it over the alice. Thank you, e ellie. Very, very interesting. Yvette. Dive in. Thank you. Thanks to a. I. For hosting, and you for the invitatioinvitation. Im happy to be here representing cal pers, and they are the largest purchaser of health care in the country. They spent 8 billion on behalf of 1. 5 active and retired California Workers and their families. They have a similar cost of utilization pattern to the national trends, so about 67 of costs are incurred by 8. 5 of the members, and 1 in 4 members has at least one chronic condition resulting in 50 total al spend which is similar to nationwide. So given the case mix and the level of spendipers calprs has increased the quality demand for the members. And they have had initiative toims prove the health initia improve outcomes, and we can talk about bundle payment, and valuebased purchases, and shared Decision Making and Case Management and incentives for i disease management. But these initiatives were focused on the insurers and the providers and while the consumer really remained indifferent to price. And so while there is a reform that consumes the same goal cores of value and not as substitute for insurer and provider, but as a complement to the initiatives. And reference pricing for knee, hip, joint replacement which is one of calprs most requested is the outcome of Patient Satisfaction and addressing the drastic cost variation in california among the hospitals which is going to vary from 15,000 to 110,000 admission without any quality of measurable difference. So referencing ann boying tton o used to run the reference pricing and describinging nit health affairs. In pricing, the Health Care Purchaser is going to put a limit that it will pay for a particular procedure and while ensuring that the limit be allow access for all patients. It is the median of all of the price points in that market, taand the consumers who provide a provider who charges less on the purchasers limit will get the standard coverage with the minimal contribute shuion, and one who selects that limit, and pays the excess amount. That excess amount paid for the kcon sumer does not count for te deductible or the annual out of pocket limit. So these are conceptual iized a network exclusions, but a milder form of those inherent in their own network befit designs. And in other words, reference pricing is full coverage at cost proeffective providers and coverage at more expensive providers where the narrow strategies are going to be full coverage at some providers and no coverage at others provider, and how did calprs go with this. From Anthem Blue Cross of california which has 220,000 basic plan subscribers they established a threshold of 30,000 for single knee, hip, joint replacement for hospital stay, and if a member does not designate a specific hospital, and the provider charges a maximum of the threshold, the member will pay the excess between the allowable and the excess. So after careful analysis of cost, and Member Distribution and geographic facers or the they performed ten of the surgeries on the calprs members and payment thresholds and high qualities such as university of california and cedarssinai and loma linda. And then in 2012 calprs began for cataract and arthrooscopy and faced a difference of to surgeries of 1,000 to 16,000 for cataract removal, and then 1450 to 15,000 for the knees. So it is structured differently. If the member can go to any ambulatory surgical scenter or they rereceive 2,000 for cataract, and 1,500 for colonoscopy, or cataract outside of agency, so if you go to the o ohpd it is a different price. So the afc was about 2,250. The colonoscopy is really between 1,000 and 1,800. So the results, those with a good or better clinical experience. The hip replace and knee or hme. And it is credited with cumulative savings of 5. 5 million over twoer years. For cataract, we showed the use of ambulatory centers from 60 to 19 . And the average colonoscopy price declined 45 per procedure. So this Pricing Program is credited for kcumulative saving of 1. 2 million through the first two years and knee and shoulder, the arthrooscopy procedures fell by about 40 . So this is a price redduction and na slowdown. For the hip and the knee replacement, that is a hospital market story where they expanded the number of facilities from 46 in 2011 to 72 in 2015, and for cataract and colonoscopy, that is a consumer story with the increase of the use in the lower costs high volume facilities and the savings came from the consumers going to the more Cost Effective ascs. Obviously, significant policy considerations that come with the Initiative Like this. Appropriately constructed programs have a number of Consumer Protections builtin. They have to permit exceptions based on the clinical needs and the e geographic locations of the individual patients. In our program, our people have options of where are to get the care, and able to get it locally. We did an extensive amount of communicating with the members to make sure they understood the options which is critical. And calprs provides the exceptions when a resident lives over 50 miles from the se vis price. It also gives the patients physician a justification for the higher priced a facility or the setting. And so reference pricing can only be done with the shopable procedures. Routine hip, and knee and joint surgeries are elective. And other shopable services in health care scheduled hospital procedures and ambulatory procedures and Laboratory Tests and imaging and drugs. One study estimated that 40 of the Health Care Spending is for services which patients could shop for. Also, a policy developments have to be watched to ensure that barriers such as october of pocket limits that do not allow for reasonable Consumer Incentives and the company protections are not put into place for large selfinsured employ yeariers and the the reference allows you have easy access to price and quality day and the level of transparency that is not common place. So finally, the applicable of the reference pricing to a nationwide purchaser and or a public payer like medicare . We only did this in california with californiabased members. For a nationwide purchaser, there are additional and challenging considerations. You have to identify an adequate number of pricing a facilities to maintain the access to local care, and on soldation may be an issue in some areas of the country, and you have to maintain the contractual relationships and see if the prices are set locally, regio l regionally or nationally, and to undertake the pricing, the price sharing within limits so it is tough to apply it to tra dailgs medicare, but however, the medicare advantage, because they have cost shaying advantages, and to exclude providers from the networks could use the ref are rens pricing. And also, pursuing the reference pricing for Prescription Drugs in medicare has been discussed and for example the part b which was proposed but never finalize, it could be examined in phase two. Under a proposal like this, they would ear marc instead of benchmark iing all drugs in tha category. E it could be the amount that the agency xrs the most Cost Effective in the group or some other group that seeks to narrow the variation of what is paid for similar drugs tmt bottom line, with the ad kwats consumer productions, you can address the costs and variation and engage the consumers and maintaining quality patient experience, but it has limitations in terms of the applicability depending on the organizations flexibility and scope. I am hearing one pattern here, and a lot of things that work, but they may be hard to apply universal ly, and that isa difficulty. Sally, tell us about walmart. Thank you so much. Thank you, alice, and thank you for sponsoring this opportunity to share what some a few of the employers are doing within our own Employee Health plans. It is interesting, because i think that you referenced power, and due to the size, but i am not sure that any of us would agree that we possess any market power even though we are as big as we are. You buy a lot of stuff. You buy a lot of stuff, but it is very distributed and a lot of the Market Forces that we are dealing with. So, i dont know. That is one part of the challenge that we face everyday. So at walmart, as alice said, we do have a lot of associates we call our employees associates. We have about 1. 2 Million People, and we provide Health Insurance within the United States. More of course outside of the United States. So we are involved in many health plan, but distributed in every zip code in the United States which is in and of itself a challenge. So as we are look across the entire population, we do and have used a number of these different mechanisms right here on the panel that we have talked about. What i want to share is what we have done with the bundled pricing, specifically related to our centers of excellence, and so our initial drivers several years ago were not really about the cost of health care or how we paider for health care, and we knew that it was important, and the biggest driver is around the quality of the care that is provided to the associates. There is a wide variation in both cost and quality across the United States. We know that the we have patients going to providers who were not getting quality, so we wanted to make shure that the associates and the patients and the family members knew where to go to get the best quality. So we focused on creating centers of excellence. We focused on first procedures where it was, there is little dispute about what the protocols should be, and certain cardiac care and spine procedures. We went about finding a handful of facilities that are top tier highest quality and not that these are the only facilities that are top tier, but we want ad small number that are geographically disbursed that would mean our high qualityb bareriers or limits. As we developed we wanted to have a alignment between the facilities providing the care and walmart. We were al lind the p were al the primary focus is quality and not just dedelivering care. What we did is to create a bundle, and it is a prospective bundle, and that is an important word, because it differentiates between the way that bundles may be creakree yacreated and in pa with medicare and Many Companies are carriers and they createt retrospective bundles, and after the fact, you will have the total direction. And we work diligent ly with th centers that we identified, and we the amount that we are going to pay for the care and then went on to define what the amount of the care or not the amount, but the kinds of care that could be included in the bundle. So two things. First of all that amount that we negotiated was not very different than what we would have paid for the traditional fee for service. So it is not about knee yaoesh gating a price or low price, but it is about creating a scenario for the provider that would say, look, we are going to say we will pay this amount, you determine all of the care that needs to be delivered within that bundle, and whatever it is. We are not going to try to dictate what that care is. We will not limit you nor are we going to encourage you to provide care. Clearly, they also have certain requirements of delivering the outcomes that are high quality outcomes, and we picked the high quality providers to begin with, and we wanted to make sure that they are going to deliver high quality outcomes. The bundles are they include the preop, the surgery, the postop and the return home. So it is the beginning and the ending are defined. There are are two bundles though. There is the original bundle, the first bundle which is an assessment bundle, and the associate who has 100 coverage if they have one of the procedures needed, and they want to go to the center of excellence, they are going to have procedure covered 100 , and no deductible or coinsurance or whatever, because it is paid for. And in addition, the travel with a cotaker to go with them for whatever period of time they need to go to the facility. They go to the facility, and a team of clinicians works with that patient to first assess the situation regarding their need for surgery. The team works with the patient through shared Decision Making. Through conversations with physicians who are specialists in their own areas of expertise and make a common decision amongst the team of whether or not surge i have actually indicated the team alsoigators facilities and all of the people involved in the discharge planning and a Team Involved in the integrated across the facility. They make the assessment of whether or not the assessment is necessary and the patient if they decide that the surgery is not necessary, they will find out collaborately to figure out the issue. So they are there because they are not feeling great, and they will figure out how to facilitate the care. So the bundle does not encourage them not to have surgery, but the bundle encourages the facility to have the best care, and if it is surgery, they will cover it. The bundles are risk adjusted so if they come in with a number of comorbidities then the amount that is paid is adjusted because they need more specialists and care given when that patient is in to a facility. So we are tracking of course, all of the outcomes, and they are really great outcomes. The patients are coming back to say they could havent had a better experience. They ask questions like why isnt Health Care Like this in my neighborhood which is a painful one for us to hear. But we are and it is interesting, because the facilities that are working on, work working in this arena for us talk to one another, and through the structured conversations, and they share the best practices. How are you treating this kind of a patient thatp comes to you with this set of criteria . What are you learning about this . How are you treating . So there is an elevation of all of the centers of excellence of how they are learning about how to treat these patients. We actually were surprised, pleasantly surprised, but pleasantly surprised for the number of people who went to the centers and determined and found out that they did not need surgery. It is happening that we started with the spine surgeries and the heart surgeries and expanded to hip and knee surgeries, and we have now expanded into the bariatric surgery and cancer which may or may not be surgery, but it is the center of excellence for the treatment. And the surprising thing to us is the number of patients who go to the center and discover that they dont need surgery at all, and they need a different treatment regimen which is happening in every one of these areas of expertise. In the cancer area, it is shocking how many times the patient goes to our center of excellence and determines that they actually have been misdiagnosed and or the treatment is the wrong treatment. Ka cancer treatments are really, and we all now how to treat a particular kacancer is very, ve difficult, so figuring out the right treatment is job, the most important thing. The savings that we are experienced at walmart are not about the fact that we have negotiated a bundle or that care is being not given because we incented the center to not deliver the right care, but it is because we are determining that harmful care might have been delivered to the patient, and we are avoiding that harmful care. That is our experience with the bundles. Sally, you said that the first was the assessment bundle, and then presumably, you have the treatment bundle. Yes, correct, two separate. Okay. Good. Okay. Joe. Thank you, alice. Good morning to you and thank you for hosting this morning. I want to focus my comments around the organizations and direct contracting that boeing has been doing with the provider community. This is really is from the frustration that the employers feel about the high cost of health care, and we spend 2. 5 billion and we have half a million covered lives and smallerer than some organizations and different from walmart that we have pockets of high concentration of employees that does not form our strategy p for the Accountable Care organizations, but yeah, it is a frustration with not only the line item of health care expense, but the year over year trend that we are experiencing. I have been many this business for a while, and it is difficult when we think that a 6 or 7 or 8 trend is decent, and we have to solve for that, because it is not accountable for the long run. So we asked the employees to pick up more of the tab. We believe in the consumerism of the hsas and it is a great strategy, but we wanted to take more of a step to work more directly with the supply side of thing, and move ourselves into the space in a more meaningful way to help drive more accountability and what we were paying and ik coe sallys comments of maybe it is not the line item that is as frustrating as are we getting the the quality that we want out of that line item expense for the company. So we moved into the space. Traditionally employers contract with the companies or the tpps and we decided to go to the directly provider system, and it is not that we didnt feel that the Insurance Companies were capable in this instancek, but we could go to the table with a clear understanding of boeings population and understood that the investments that with have this year will pay dividends three or four years, and we have longtenured employees. So hospitals taking a risk, we could understand a easier conversation about the risk than an Insurance Company about the market risk and people coming and going and a much more complicated discussion, and that is why we went directly to have these contracts in place. We have five of this them around the country, and that are live n now, and we have 30 of the eligible population is enrolled in one. And maybe different than medicare acos, the people will go through the annual process and elect to be in the acos and they know that they are in a little different program. Essentially, how it is set up, the contract follows the triple aim in health care. We align it on three principles improving Member Experience and improving quality and the value that we get for that. Ly touch on each one. From the quality perspective, we we have deuced 15 nqf measures and looking at more marketers than that, and we wanted to not putt 100 in the contract. So it is a wide spectrum of the clinical outcomes, Preventative Care screenings, and csection rates and that kind of stuff that we measure and hold the systems accountable for. And the member stuff is softer and things like a 1800triage number to have the patient navigate the system. That sis a daunting task especially for those seeing multiple doctors and hospitals, and this is important to have the triage help, and they have dedicated websites to give the em moi yployees access to the electronic records and emails and things like that, and that was happening, but we moved the needle on how quickly it is happening. The real meat of the conversation was aroundle aligning the Financial System s with the care, and until we do that, it is the fee for system world and paid for volume and not quality that. Part of the contract is the actuarial model is complicated underneath it, but at the center, it is to incentivize the employees to elect a aco and go get the care in the e integrated health care system, and they get most of the care, 95 or more and that is going to drive volume and revenue into that particular hospital system, and in return for that, they are willing to guarantee the ip take risks, and the financial trend for us over time. If they need meet the financial targets and the quality targets, we will share the savings back with the system. And you know, the systems are five of them. We will see Different Levels of performance, but we feel very much like we will be cutting a check to some of them for the performance which is our goal in the end, because we want to pay them back because it means they met the goals. So that is what we are pushing for. So it is great to have a contract ta aligns incentives and you ask, how do they get this done, because they have a daunting task. These are aggressive financial targets, a and there is a figure out how, the integrated system how the deliver care in a more e efficient way. And again, varies by the systems, and i think that they have done a desent job of analyzing, how are we going to deliver care more efficiently, and you can look at it in different pockets like the Spine Surgery for example, and happy to pay for the Spine Surgery if it is 100 necessary, but a physical therapy would gox and we dont want to pay for that. So it is a conundrum for them, and it is a revenue generator for them, and now that they are held accountable financially, they are installing the right protocols and pathways that we go through the right procedures before we do expensive procedures like that. And Prescription Drug management is another one to see how they can manage thatt better. We would not expect the physicians to understand boeings formularies against others, but i would expect them to know that if they are going to be prescribing drugs, it should be generic, and we have seen a good uptick, and we give them almost real time drug data as part of the arrangement to understand which of the physicians are outliers in the prescribing patterns. Investment in the Information Systems is important now that we are directing the employees tot get all of the care within the integrated system, and they should manage that patient better, but they need to make sure that all of the systems are talking and a shared care project, and all of the doctors interfacing with the patient are operating off of the same integrated system. That is a big thing. We have talked with some systems that even the compensation structures that are historically rooted in the volumebased compensation, they are are making steps towards lets introduce more quality compensation, and that is an important piece here. And it is a step of movinging a away from the fee for service medicine. Again, it varies by system, but those are some of the big things that we are seeing them do immediately to try to meet these financial challenges. In terms of the results, with are pleased wi we are pleased with the quality we have seen. And our mbs like it, and the focus groups, the members usually rate the acos 8 through 10 so they like the services. I would leave you with a couple of specific examples that get us excited. Of course we want them to meet quality and financial targets, but we are excited about what some of them are doing in the specific pockets. I will give you two examples. One is econsult, and this is a big thing for our business from the productivity standpoint. Historically, somebody goes to the primary care physician, and unusual and if they go to the specialist, it is another four hours a wway from the office an the production line, and another Specialist Hospital care, and if the they can do a econsult in a meaningful way with a specialist without having to send the employee back to the system, we may not see it on the claims end, but the production is hugely important to us. And cool things like that. And the other thing that we are excited to see is e Bep Haverhill health. You take a place like washington, seattle where we have not historically had a lot of managed care, and Behavioral Health was not talked about at the primary care level and the physicians were not good to address the physical needs or the Mental Health needs, and the data is extremely clear, and everybody would know that. Depression is comorbid with every other condition, and needs to be addressed, but there is no reimbursement mechanism for, that and i would not blame the primary care physicians for not addressing that in a more meaningful way, and so some of the systems are trying to e integrate Behavioral Health into the primary care clinics, because they know that they are financially responsible for folks over the long term. They can see the value and the investment of that and the reimbursement mechanism is going to follow, and people can sort it out. So we are excited to see the bigger delivery are system changes like that, and figuring out Behavioral Health. We have seen them doing to be more enterprise approach where a psychiatrist is triaging folks or even integrating a Mental Health specialist into the clinic, so it is can be a warm transf transfer, so it is stuff like that where we are more optimistic that it will enact some change by forcing accountability to them. I would leave on that note of optimism that sit is a multi stakeholder issue that the country is facing, and we need t the employers and policy makers and the Insurance Companies and the provider systems to come together to figure out a way forward, becauset is not one entity to be able to solve for this. I will leave it with that, thank you. Good, thank you. One thing that you mentioned was that they, the employees have to elect to be in the hco which is always seeming to me to be one of the failures of the medicare sponsored ones that you may not even know that you are in it. But if you have to elect to be in it, that is goinging the give you an opportunity since you know that you are there to engage the patient in their care. And maybe to do some of the things that ellie was talking about in getting the patient earning some points to by doing things that are good for their health. Is any of that happening . Yes, that is an important aspect of it. That they know that they are in something different, and we dont go as far as requiring them to select a primary care physician, but we strongly encourage them to, and that is part of the enrollment process, and we believe in engaging them with the primary care physician, and if we dont e lkt one, we have the aco Network Reach out to them, so there is an opportunity for that, and generally speaking, they expect to have a different level of care throughout the year in the aco and they expect to be reached out from the system. So we are setting them up. I think that we could be more aggressive in terms of requiring them to be a little bit more engaged, but we want it to be viewed as incentive only for our employees only at this point in time, and other employers or stakeholders could be more aggressive. And the aco, itself, they could be. Yep, yep. Lets open an opportunity here for the members of the panel to the perhaps question each other. Or it does seem to me that there are some things that some of you talked about that could be picked up by others. Did i hear you say that you incentivized them to join the aco . E yes, the incentive for sine employee is 300, and over 1,000 for the family, and so there is a Strong Financial incentive for the families to consider joining the aco. And obviously, that is going the drive that is going to drive a certain amount of participatio participation. Did you penalize them from not joining . No. We have Employee Relations to where we want to be incentivizing them. Yes, yes. But you could, you could do that if you were in a particular situation, but not for boeing. I wanted to ask about the outcome measurement, because everybody mentioned it, but i think that the ad jen ta is that we are not there yet, and to agenda is that we are not there. Have you made any progress in mez shoeing the outcomes . Or the difficulty . E was going to say that we are live with some of these for a couple of years, and we are little early in providing, you know, statistically significant outcomes. We are pleased with the leading indicators, but some of the challenges in measuring appropriately is that there is a selection bias, and healthier people generally select the acos and we have to solve for that and make shure that we have enough data to credibly measure the outcomes, but as i was saying, that we are encouraged with the relationship that we have and what we see in the integrated systems doing to change the care. So it is, yeah, a little bit early for hard objective data for at least our program yet, but the leading ipd k ing ind k thes indicators are looking good. And in our population, it is limited outcomes, because we know who went and what they had done in the centers of excellence. Centers of excellence . Yes. And including some anecdoteal patient reported outcomes which is not captured as sta cltisticy are reported outcomes as good as they could be reported. And the measuring of the difference of what you could have paid and what you did pay is the quality of metrics that you have to look. And the quality measures are hard. They are hard in every health purchasing initiative and im not sure they are quite right anywhere across the boards. That is what is needing more work generally. And i would say that we are all focused on that ultimate indicator of the health risks of using the progress and how we want to look at the ability to look at the wellness dollars. And what about the well nene dollars. Yes. There is a positive correlation. Have you found anything startling like if only you ate your breakfast, you would be much healthier . Well, it is not quite that simple. But we are investing in helping people who earn their dollars. Right now, we have about 60 who do earn the wellness dollars, so it is a significant opportunity of people who are leaving the money on the table to use to offset the medical expenses. And so, you know, we are talking earlier today about, you know, the advent of the iphone and the other devices to make it easier, so we have upgraded the whole wellness platform so you can do all of the activities in the palm of your hand. And we have very different populations, my guess is represented here. At least, i have not researched this, but i expect that, jeff, the population is quite high skill and high paid and sallys is quite lower skill and lower paid, and i wanted to wonder if particularly you talked about the centers for excellence which is a smallest piece, but how is your Health Care Delivery affected by the fact that you have a large number of quite low income people. So, it is really important to us to be able to offer plans are affordable for the employees. So the plans are less than 20 every two weeks for Different Levels of plans, but they are not bronze plans that are very low and these are nice coverage plans. So affordability is primary for us, for our associates. And the only which that we will provide the affordability for them is to provide the highest quality and eliminate the inappropriate care and have them have access to the best providers, and so we will focus at it from that perspective, and we dont, and what we dont have is the luxury of, if you will, of having people, the preponderance of our employees dont work for decades as opposed to a population where the are preponderance is to work for decades. We are often a first job or the last job for an american. We have a lot of people who work for us their entire career, and maybe they started out as associates and become ceo one day, and that could happen, but we dont look at it at the same standpoint of 5 to 10 year perspective of the health, but we are look at it the what we can do to help the health care today, and not considering the long Term Investment or not, and we want to know how we can help someone with their health today. And yvette, the population is more long term, and to think long term about their health. And so i mention ed at the top, and i think that our Health Status is like the National Population is with a number of chronic conditions, diabetes, et cetera, so i dont believe there are any less health iier or mor healthiers inially because they live in california, and but they do have us a long term, and we have retirees as well and we do track the health kcare and the wellness longer term, and that is a difference. We have the geographic issue that is nationwide that is more difficult and it could drive somebody to the centers of excellence in the program as opposed to the networks. But then we also have them, have a longer term focus which is helping the initiative. Also open to the audience who is asking questions at this point, and i believe there are microphones coming around and tell us who you are and when you are getting the microphone and and making the question a real question. Right here in front. Thank you. This is a terrific panel. Im leah binder from the health care group. Right new in washington what we are doing with the health care coverage, and neither one of you have mention ed a have mention ed Health Care Plan, and have have you considered the debate around health care reform, and what would it be given your experience of the Health Care Plan . And so, i think that one tof the focuses of this panel in this day was about innovation. And what you sh, if you are loog back over the history of unnovation in the health care space, and leapfrog itself is an example where the innovation came from the private sector and employees to identify any, and look at the ways to solve it, and then as the time goes on, then the health plans, because, theres some opportunities to identify, and some ways to learn from it, and proceed on and so we are seeing the health plans that are learning from the early work that wells fargo did around the consumer productive plans that the health plans began the really engage in that, and the reference pricing, the bundles, and the acos. So it is not an ooeither or, bu it is sometimes that the innovation starts from the focus need and employ year and expands to the health plan. That innovation is expand iing, and it is also going to kind of go to other way, and innovation could happen within testimonims are capitalizing on and that the health plans, and so it is not chicken or egg, but it is a little bit of the ability of us to work together. Yes, it is calprs working closely with the plan, and so it is highlighted by anthem of blue cross of california and so we work with plans that are selfinsured and fully insure and so they help with us the implementation and tracking the outcomes in terms of the claims to figure out what is actual hi happen actually happening to the member. And the health claim is critical to the acl and to the traditional generation, and they need to quickly give data to the aco partners in the way they are not used to, and so, critically important but in a different way, and i would say that that the health plans are moving towards more valuebased purchasing and some smaller employers and the avenue that they would need to go through to enact that. And i would put it in as a stakeholder, and it is for the foreseeable future, a stakeholder to figure out how to drive more accountability, and no doubt about it. But following up on the question. And what about how employees choose health plans, and i mean, well, you started to say that you have a choice of three, and you are talk about two of them, and what is the information of the employee have to make that choice . It is a great question, because i think that health care can be extremely confusing in terms that we all throw around, and you know, dont make a whole lot of sense to somebody whose plan is different than what we do. So we have decided to invest in significant feature s fs for Th Associates to have in that enrollment flame, and we have a virtual benefits counselor, who is a fun and irrelevant irreverent guy, alex, who is produced by a group jellyvision who will walk people through the questions, and what is important to you, and what is the family situation like, and how many prescriptions to you have and what is the overall goal, and then walk through which of those plans might be best and the pros and cons of the different plans of explaining that, and using it not only for medical, but all of the benefits. So it is an Electronic Exchange with the animated guide. Animated guide . Yes. And then we wrapped it up with call centers, and the people that some people like to do it online and some people like to pick up the phone to talk to somebody and we want to make shure that all of our members have those options. Other questions . Thanks. This is a fantastic panel. So we have heard of several tools for really better driving Decision Making by the patients, and by their Health Care Providers or professionals and from the financial to the shared Decision Making, and i wanted to ask sally, because i was interested in the mention of the shared Decision Making tools and the effect of the outcome of, you know, people kind of deciding that maybe they dont need the more expensive treatment. So i am wondering if you could talk more about how you decided to incorporate that into the bundles, and how did you figure out the tools to incorporate, and how essential to keep the outcomes that you would use . The answer to the first question is that there is not a tool. It is actually a literal meeting between the patient and their family members and a team of clinicians. So, we didnt put it in a tool that some of you may know about it, but it is a decisionmake, and the ultimate shared decisionmaking where everyone is informed with preferences, clinical information and all of that thing. So it is built into the process. And this is it is not a tool. It is truly that if you were not a if you were a layperson and you talked about the shared Decision Making is how you would describe it. All of us in the businesses, and when way Decision Making, it is a process and a tool, but it is no, sharing the decision. That is what you do for the relatively and it must be a relatively small population and a part of the population that is in such serious circumstances that it is worth it to the company to take them to the center of excellence. Is there anything comparable with Something Like how to manage the diabetes or we dont have anything at walmart, but some of the others may have the tools. Beyond. We dont have like a tool. We dont have a, and it is not a tool, but for people who are, who have diabetes, we have diabetes support programs that where you can engage with the health plans, and then also in, you know, various programs to be able to manage the diabetes in a more festive way, and so by joining communities, by having programs that are going to allow you to check in on the progress to allow you have better interactions of the care, and so there is absolutely specific management programs throughout, and so that kind of thing the attracts a lot of people. Absolutely. And some have multiple condition s. Yes, diabetes affects 9 of the people in the United States. So, wells fargo population very much mirrors the United States population. And another thing that we do is that we feel strongly in the medical home concept for thicker patients, and written in that you have a patient with fixed position, and the medical home concept is to have a nurse care manager to coordinate the care for the patient and team huddles and a shared care, and not a decisionmaking tool per se, but for the people who are using the health care in a significant way to make sure that the care is coordinated well, and there can be shared Decision Making and shared care plan with the doctors. Yes . Hi. I talked to free market monkey, and i have always felt that the Employer Division is central to the whole problem. Do you think that with the dave brat and jeff flake Health Savings account expansion act that companies would organically then go to defined contribution and where it would be as common to match a contributions to the an hsa as it is to the 401 k today and employers would have ownership . Do you think that we would be in a lot better position . Anybody want to take that one . I will be the brave one. You can offer your opinion. I dont know if it is better or worse, but i think that the employers which i talk to are predominantly large employers and the focus is on providing affordable Quality Health care. If all of the offerings within, i will use the shorthand of the exchange or the marketplace were Offering High quality affordable plans, there is, i think some employers who would think about arranging the delivery of the health care that way. I think that there are employ yes that you have just heard today, there is innovation that happens at the employer side, and the private payer side that has been valuable to the system with respect to changing the Delivery Systems and encouraging positive outcomes. I think that there is still going to be a portion if it is a large portion or the smallest portion by a number of companies or the number of employees, i dont know, but i think that the innovation that we strive for will continue to exist and even if we move to a different model, we will continue to innovate within that model. So i dont know that i would say it is going to be, you know, everybody is going to move in one fell swoop nor do i they everybody is not going to move. It is toing the be a split. That the early readings of the last couple of years is, and not Many Companies have made that decision to this point. I would like to add to the comments for contacts. One is shared incentives, and it is absolutely in the team members best interest to be healthy for obvious reasons. It is in our best interest that they are 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 the wells fargo or from the walmart or the calprs and they will take advantage of coverage under medicare, so we all have this shared interest, and so, how that happens is impactful on all of us, and i think that all of us as employ years, regardless of what the current structure is or what is legislated from a health care perspective, we will make decisions to make sure that we are going to make decisions to offer that affordable, and comprehensive health care for our employees in a way that makes sense for our companies, and when you are looking at, you know, a lot of the provisions that is under todays legislation are required, many of those provisions, employers have put in place, and they had been in place for a long time. So i think that we will always continue to evaluate the structures available, but at least for us, we are overriding that with that broader objective of we need to provide our emmel pl employers with a comprehensive health care approach. Yes . You mentioned the implementation, and i think that health care is very important, but it is also for consumers and patients and their families who are mostly ignorant, and for some reason, they dont know what happens, and then especially if you are calling in a distressed or mental illness, they are already diagnose and so the laboratories and the others and it is more arbitrary, and so it does matter the point of view how you save yourself and the Employment Company of the resource, and also save the patients, and not only their health care, but their life, but also their lifetime savings and their family life enjoyment. It is its very important, very significant, and very increasing segment of our health care. And nobody seem to really have good all together Society Point of view, maybe even Government Health care. So i just wonder if you can address just we agree that, yeah, its daunting to go into the Delivery System. And i think there is various advocacy approaches that employers are taking, some really successfully. In our particular one weve asked the aco to take on that responsibility. And my comments about Behavioral Health, yeah, that needs to be embedded at the primary care level. I mean, that seems to make sense. But i think its there is a role for advocates helping our employees through the system. Its very complicated and very stressful. There are a number of vendors that do that. We feel like that should be done by our aco. They have that direct contract that enables that. But not everybody has that so there is other third parties that can help that. I agree with you that something needs to be done to help navigate through the system. Certainly the experience of the Affordable Care act was that it was essential to have navigators helping people, especially people who never had insurance before, which was the population they were aiming at. Yes . In the back. Hi. This is a great panel. Paul heldman withHeldman Simpson partners. Im curious on the wells fargo experience what other data you might be able to share on the impact of hsa high deductible plans on hospitalization and the other areas that you mentioned. And then sort of more broadly for the panel, you know, as you know a lot of the debate in washington right now is about the individual marketplace and medicaid. And im curious whether you have any thoughts on what are the impediment or adjustments in law that need to be made to make the initiatives that you are discussing up there work in these markets . So give me a little bit more what you are looking for from the hospitalization side . I read that there is some concern. I dont know whether there is any data to support this. One of the concerns that over the long term because of the drop in drug youth niesation that you mentioned for example utilization that you mentioned longer term it might lead to more hospitalizations because people are not using drugs when maybe they should be. More broadly im wondering if you can provide any data on hospitalizations. And also in the areas where you saw a drop in utilization, sort of in percentage or some other terms, what kind of drop you saw in there, what kind of increase you saw in preventive services. Yeah. So probably the most signatuifit change that we saw with this population was the increase in their engagement with the Preventative Service with going to see their primary care physician. Thats a 20 increase with this population. And that we believe is really the enabler for everything else. Right . If you have that ongoing relationship with your primary care physician, then that allows you to say, am i on the right am i on the right drugs . Right . So the drug difference was not as significant of a decrease. And a lot of times we find that people might be on the wrong drug regimen when you look at what people are doing. So the drop in hospitalization was really in e. R. Usage. Thats where you see a difference in populations. And part of the comparison is when were looking at our population that uses the Health Reimbursement account versus those with the Health Savings account. A key distinction is that a Health Reimbursement account, this is the account that has the more firstdollar protection. We see those accounts with additional dollars from wells fargo depending on your income. Okay . So the way that those work is that when you need medical care it is 100 paid using those dollars up to the amount thats in that account. And so if somebody chooses to go to the e. R. Using one of those accounts, ill fully paid versus if somebody goes to the e. R. For using a Health Savings account thats going to have a more Immediate Impact on them and their personal pocketbook, right . So you are going to so that difference. So i think what we are seeing from a consumerism standpoint 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 e. R. . Or might i go to urgent care instead . And thats generally a positive behavioral change that we would see as a good thing. When its coupled by that improved relationship with the primary care physician. Right. So just in percentage terms, what was the drop . Im looking for more specifics. E. R. Use i think was about 5 drop. Okay . Does that get at your question . Yeah. Okay. Yes . I think i see a hand back here. The lights are rather bright in my eyes so im not so clear. Here we are. Karen fisher with the aamc. Im curious elie if you could work through the numbers in terms of how much goes into the Health Savings account and what the average premium is for the high deductible and how the 800 fits into that. Sure. So ill use we have a lot of Different Team member groups and choices that people can make with their health care. Ill use the example of somebody who is electing single coverage. Okay . So they are able to fur single coverage and you are making lets use a lower paid team member just to give some examples. If you are in our silver plan, your annual premium is about 750 a year. So about 30 per paycheck. Were a lib higher than you, sally. You are at 20 a paycheck. We are at about 30 a acheck. Then you are able to earn up to 800 a year in wellness dollars. And then i think you might have asked your individual deductible would be 3,000. Yes, thats what i asked. Okay. Are there other questions . Yes . Do you contribute anything to the hsa or the wellness, the 800 . We contribute the 800 wellness dollars. We do not contribute to had had sa. If that he choose the hra, we contribute for that team member they would get 700. Then they could also earn their wellness dollars of 800 on top of that. Yes . I agree, this has been a terrific panel. My name is harris allen. Im a consultant in health care. Two questions. The first observation is we are talking about four different basic initiatives that have really would appear to have made strong strides towards improving value in health care. Very distinct, different, but all originating from employers. All right . First question is, has there been any effort to look at the impact to quantify the impact of our initiatives on organizational performance or profitability . The second question is have you seen if you are taking steps that is increasing creating a culture towards value improvement, are you seeing this rub off on the on other stake holder groups with whom you are interfacing above and beyond your direct engagement with them on the initiatives you are talking about . So two different questions there. I can go first. I think for our specific initiative we are able to quantify what we expect i assume when you say organizational, financial outcomes for boeing, we were able to generally understand what we think this program will yield over time in terms of savings. We have a good idea on that. But its variable on performance in any given year but we expect to have material savings out of this. I think providers would say they dont treat boeing patients different than other patients. So inasmuch as there are some Delivery System reforms like the pay barrel hope thing i mentioned i would think that would be accretive to other employers or stakeholders using that system as well. My hope is that that would be the case, if we help them change the way they are delivering care that that will be transferable. And then i think there is also in washington at least, the state of washington, pretty quickly followed a pretty similar contract at boeing and improved it with some different Quality Metrics that we really liked as well. So i think there is some follow on pathways to doing similar things that we are doing. And i think it would go for all of our examples. So i think, you know, follow on opportunity for other stakeholders within the Delivery System. Yeah, i think thats exactly right. I would add obviously every dollar we save goes back to california taxpayers. So its important to us we get the highest return on investment for our health care dollars. I dont think there is any doubt that amongst the stake Holder Community the focus on value as opposed to volume has permeated all the stakeholders, including the plan, the providers, our members. And that has come, you know, from the federal level, from the federal purchases, from the employer purchasers, and at the state level as well through medicaid. So i dont have any doubt that this has sort of permeated and that providers are changing the way they practice, whether its because of our initiative or boeings initiative. That that will move through all of the patients that they see in terms of having a different focus on how they practice and whether its really volume driven or value driven. Ill answer the question a little bit differently. I dont know if this was the question that you were asking, whether or not there was an roi or an organizational impact. We havent studied the organization clear the savings, thats just 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 profit or whatever. And while we have not studied that at walmart with respect to the deliver within our health plan we have studied whether or not our Wellness Program, our with being initiativesv have provided a positive impact on our business. And we have been able it was statistically difficult to do because there are so many confounders and things that would well, the weather was better this month, or you know, the christmas came earlier or whatever. But when we really tried hard to do something that was very statistically sound and eliminate all of those confounder. What we what we discovered is that in our stores that participated in our Wellness Program to a relatively higher degree, there was a net positive impact on sales in those stores, sales per square foot in those stores versus stores that for whatever reason the store didnt get engaged in our Wellness Program. So so we have done that assessment because that is kind the you know, from a corporate point of view, is, you know, are we actually adding back value to the company . And we did do the study with respect to our Wellness Program and found that it did add value. Its sort of those questions, is wellness really worth it . It turns out it actually is and it actually improves sales in our scenario. I think we have time for one more question. How about right here . Bill signer again with the corpsman group. I think this is a great panel. I think what you are doing about focusing on delivery reform is very important. Its an essential thing to help the patient to figure out what they need to do, whats the best treatment for them. I know there is a lot of emphasis on cost. My question is, where do you factor in, or do you factor in the need to train the next generation of physicians, the need to do research . Is that part of your if you are always looking for cost savings, does that ever factor into it . We talk about that that needs to be done. I dont know that whats your responsibility . What is our responsibility as the payer . Yeah. Thats a good question. I dont know. Ill look to others. I would say one angle of that is you know we work with our health plans to ensure that all of our payment structures are based on evidence based medicine. Right . And so you know all the medical directors that we work with are ensuring that our programs are aligned with that and then that goes back out into the medical community. So id say that would be the angle that i would say we are connected to. But i dont i think you raise a good question. But its not part of our broader conversation at this point in time. Let me pick up on that to ask a final question of everybody and come back to public policy. 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 you are trying to do to have a 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 any anybody, including federal government or state and local governments is to focus on aligning incentives and providing a competitive marketplace that focuses on the appropriateness of the care thats delivered so that there is there are Market Forces that come to bear, there is transparency that allows us to understand the differences and that its focused on making sure that the care thats delivered is the right care and that no harm is done to the patient. It sounds lofty but just focusing on appropriate care that piece of inappropriate care said differently i think is the one thing. I think in the broader market, obviously the provider is going the react to the incentives and the quality of medical care that medicare puts on the table because its so big. Its helpful to others if medicare helps align providers in the same direction that we are trying to align providers. I think thats one thing. The other thing is the federal governments ability to investigate and try different initiatives on whether it be on transparency or consumerism or research that informs on what works and what doesnt work, that informs the employer and other purchaser communities is really something that can only be done at the federal level. And then kind of provided to other purchasers who can use that as a model. So that is an Important Role that the that needs to happen at the policy level here in d. C. I would you know n the context of hsas, i would support a giving us a little bit more flexibility in how Preventative Care is defined, and being able to you know, today preventive compare is outside of the deductible. Thats been very helpful for people utilizing hsas, but what it doesnt take into account is Preventive Care for people with chronic conditions. Somebody with diabetes, their Preventive Care so their condition doesnt advance could include things like foot exams and insulin treatments, et cetera, and those things you have to meet the deductible before those are covered at a higher rate. So we would like to have some flexibility in how that is defined to care for that population. The other thing we would love to see is we have a lot of veterans who work for wells fargo. Its a really important part of our population. And because many of them are covered under tricare or utilize va for coverage, they are not eligible to an hsa. So thats a population that we would love to be able to have that same choice. Thats interesting. I would say similar comments on alternative payment models, alternatives to feeforservice are important. Paying for value. I dont know there is one model that would work in necessarily every market or if you have different issues with rural and urban settings but driving towards pay for value is critical to the longevity i think of the system. Another key element that folks mentioned, the transparency. Enabling our employees to fully understand cost and quality at the point of service will help fix the economic model. There is just lack of information there. So i think that will