so the initiative in the affordable care act focus on prevention and wellness has been talked about for decades. but he did finally we have an opportunity and a platform to really get serious about them. and it's everything around rewarding providers for keeping their patients healthy in the first place to looking at strategies and models that we know work. we know that there are very promising indicators that the medical home model works and works very well. but again, it takes a team of providers, often not necessarily has to be a physician intervention at all times, but the coordinated care strategies involving the medical teams with nurses with home health workers, with a variety of caregivers to do a brief name or preventive care to follow up care can be extraordinarily successful. but built around a primary care provider. and we have just recently added medicare to the system of medical homes that have been in place now with private insurers in parts of the northeast and in the colorado area would want to make sure that medicare is also able to participate in those efforts. the affordable care act as susan said that allows us to move forward unaccountable care organizations. .. another huge investment was made in the recovery act which i think will then help enhance the primary care system is the investment in health information technology. i would suggest that all too frequently primary-care providers are somewhat handicapped in a system without an electronic medical record where there is a in an ability to route we be able to coordinate care from a primary point of view where the car theologist has one set of records and the hospital may have another set of records that discussion and the deliberation and appropriate treatment is sometimes very difficult. what i hear from providers across the country who have made the shift to the electronic record system is first they would never practice medicine any other way. they would never go back dwinell system in fact i can't imagine how they used to practice without it also the ease with which patients record can be accessed and viewed simultaneously that appropriate treatment decisions can be made and that again i think a primary-care doctor can often stay in place as all important link with steps along the way which is virtually impossible with a paper system. in addition to just shifting to the electronic records, the goal isn't just to change everything that's on paper and just dump it into a computer and walk away but really to help drive meaningful use at every point along the way so the investments that are being made really also to capture the protocol of meaningful use and again i think it will enhance the role often of the primary-care provider in fuss dream of medical care. americans access to care is often difficult and, you know, when we think about where we are in the lots of other systems it is really ironic that our health care system is so far behind. think about the difference of ten or 15 years ago and the way that you needed to go access getting cash. you have to wait until the bank opened. you have to have a checking account and show up, make a withdrawal, show and ied and whatever else. the difference now to go to an atm machine not only anywhere in the country but anywhere in the world and put in a four digit pin and assuming you have some resources standing behind for digit pen money will actually come out seven days a week multiple languages in a country. most industries that used enhanced systems to expedite the way they do business. but we have not employed all sorts of technological advances in the delivery of medical care and ironically we are beginning to read experiment with some systems in place in developing countries but not in america. for instance in a number of pretty primitive areas, salt and technology is being used to keep pregnant women up to date on medical payments because even in a pretty developed nations there are some funds to the coup -- cell phones owned by the population. we don't yet use that and a program being launched right now, the text for baby that is beginning to experiment with just that strategy and under certain neighborhoods to try and give a salles phone to a newly pregnant woman to try to use a very simple text message back-and-forth to remind people about everything from a plant meant to fight against the steps along the way to try to enhance the prenatal services that are available. seven-up patient friendly services so people can schedule their doctors' appointments online could ask questions back and forth of medical providers could be in touch with providers without offering to take time off work, schedule an appointment, wheat in the waiting room, go into the office, you're ten minutes and have to go home. again the system is beginning to be in place with everything from minute clinics to the telehealth are beginning to establish a footprint and i would say if the potential revolution within the cincinnati children's hospital a couple of weeks ago the outpatient clinic with a mother and her daughter who had some pretty serious health challenges that has had that since birth and the mother was describing the change in the last two years where she can actually go and access provider information in a dialogue with the series of questions. they do a lot of home testing. she can send the results within 30 minutes and get an answer back about whether or not they need the provider visit or whether or not, you know, it is a change in medication or whether or not it is just take a deep breath and this will pass. not only you can't imagine the peace of mind it gives my husband and me but also the extraordinary amount of time it saves for both the providers and for the parents and the patience and i think that technology is on the horizon. enormous investments have been made and i think the recovery act investment gives the tippin point. we are confident that as more hospitals hoof and provider offices to get a vantage of this and the market will take over but we've got to get to the point where the majority of providers actually are using electronic systems or ordering electronic prescriptions following patient care with coordinated care and again i think it really enhances the opportunity for primary care doctors. so, i don't think there is any question that under way is what has been talked about for decades as a system that needed to be fixed and put back in place. work-force investments are under way and will continue to be made and it's everything from encouraging more medical students to choose primary care fields but also the more appropriate payments when they graduate from medical schools that they are not sitting with a pile of debt comparing notes with a classmate or colleague who is looking at making three or four times the amount that they might make over a lifetime and have the same amount to get to pay. that is not a very good incentive for people to look at primary care. i think that the focus on the sorts of effort we need to me for prevention and wellness have never been in place in the way that they are right now. the affordable care act actually eliminates the copay for preventive care for screening encouraging everybody for medicare patients to private pay patients to not only establish a medical home of follow the protocols, reducing the financial barriers for really enhancing that. the effort under way on channel to obesity and the prevention and wellness grants, which we've now district across the country for both obesity related efforts and smoking cessation efforts again can not only change, began to change the health profile of americans which is a very good news but again, put in place and highlight fi importance of prevention and wellness efforts. if we are able to once again decrease the smoking patterns in this country and decrease the proximity of secondhand smoke and really make a serious effort to go after what is an obesity challenge weare two of three american adults and one or three of your children are overweight or obese right now and the underlying health impact of those conditions are extraordinary. they are extraordinarily a expensive but they are also extraordinarily costly in terms of morbidities' and in terms of life span so having the that effort and initiative underway which again puts a primary-care doctor at the center of a coordinated care health care strategy. the investment and electronic records not only to have the ability to coordinate care throughout the system but have a true medical home model and a true account book your organization with an employee that the underlying technology to really allow the providers to once again be providers. i can't tell you how many doctors i talked to told me first of the haven't hired a new person in their office to deliver medical care in years. anybody in the office is to fill out forms and paperwork. you know, the front office, the building to the cobbling office is run exponentially but often the provider side is more difficult and limited and there are lots of strategies in this legislation minimizing overhead. the ed ministry of simplification that we will help drive for insurance companies so we get to a much more building form or a one-stop shop for provider form the and for billing operations and then implementing that through an electronic sister to defeat the system can dramatically shift at time elements back to delivering medical care and a way from being a clerk which too many providers spend way too much time doing and i think are eager to have the opportunity to return and then the future with every american having an had system and affordable care strategy that will again allow people and encourage people to access providers at a much more appropriate time not only through the doors of an emergency room but also seek out health and wellness care and training at an early stage will be able to build incentives around care teams and communities to outreach to the most vulnerable and most difficult populations and often do some exciting experiments with strategies that teach us how better to manage chronic diseases and multiple conditions in a much bigger to become more effective fashion than what's going on right now. so the combination i would suggest is an opportunity to not only clearly we make medical care but use the tools of the enormous public payment system to help transform the delivery system and a lot about that will aim at the primary care providers. so it is a very exciting time and a very appropriate topic to focus on and there's no question the legislation that has been put in place and the framework that has been put in place since january of 2009 really does tauscher in a new era of medical care but certainly a new era for primary care providers and i just look forward to as we get to the thousands of the secretary shall yield seized the because -- are implemented work in communities and learn what are the best practices and what are the features that we need to fraiman moving forward, and encourage and incentivize providers and systems, health care systems to deliver the best possible care to the american patient. thank you very much. [applause] >> thank you, psychiatry sebelius for laying out the tremendous foundation and we know that you have to get back to the shells. so we will move on to our first panel this morning which is intended supervise overview of the primary-care prospect excuse me and prospects for reinventions. may i ask the panelists to come up and take a seat here at the bias. we are going to you're framing remarks first from larry and i will introduce him briefly as with all of these participants. he's the chief of the division of of comes and effectiveness research and the livingston fair and as as a professor of public health and the department of public health at the weill cornell medical college. he came to cornell after nine years at the university of chicago where he was a tenured associate professor. previously he worked 20 years as a family physician and permit practice in california. he also worked extensively with schmidle trade commission and sufficient eckert and hospitals on antitrust issues to the clinical integration physicians and physician hospital organization. we are also here after that from the board certified internal medicine physician working to shape the future of the health care system and recently stepped down as the director of policy for the obama white house office of public engagement and intergovernmental affairs. before that, she served as the defeased debt director for the senate education labor and pension committee under the leadership of the late senator kennedy. before her time in washington she was a clinical instructor at the university california los angeles and associates scientist at the rand corporation. focussing on research and health care quality. we will hear after that from all this victor von professor of history of medicine at the university of michigan where he is often professor of internal medicine at the school and also history in the college of the dresser didn't covetous designs and art and the fans and policy division of school of public health. he is currently director of the grumet society of medicine and of history and he's going to be providing an overview of the history of primary-care. we will then hear from robert phillips family physician and director of the robert grand center of policy studies and family medicine of primary care. the gramm center has many of you know functions as a division of the american academy of family physicians. savage by a small research team focused on providing evidence to help inform policymaking. dr. phyllis practices in a come into this residency program in fairfax virginia and has a faculty appointment at its georgetown, george washington university and virginia commonwealth university. finally as i mentioned earlier we will hear from georgia became the seventh president of the mazie foundation in january of 2008. immediately before that he was vice president of the clinical affair is partners healthcare systems in boston and a daughter of the academy and harvard medical school. for nearly four decades he played the leadership roles in many aspects of undergraduate and graduate medical education at harvard. he also serves on the president's wife tells fellow commission and chairs the special medical advisory group. for the department of veterans affairs. let me turn things over now to some comments from larry. >> i'm going to try to frame one specific issue but i think it is an issue that if it is not addressed i would venture to say that all things the secretary just spoke about will fail. i may be wrong about that but i think this is an issue that needs more attention than it has been given and that is the fundamental transferred transformation of the physicians especially how they spend their time. right now we report that physicians and exploit good physicians and i don't think exploit is too strong a word so if you look at the rich barron's article in the new england journal of medicine this week or last week and keep see the volume of the phone calls and e-mails and other non-visit based care physicians and the practice provide it is stunning. these are good physicians and those things they do for patients are very high volume. there are many physicians in the country who don't do those things very much that they see a very high volume of patients every day. i can tell you from my inexperience and practice those are the bad physicians. they might see 40 patients in a day and go home at 6:00 and they make a fair amount of money. what i am calling to get physicians see more like 20 patients a day and go home at 9:00 or 10:00 at night and provide high-quality care and lowering health care costs by what they are doing but they are not rewarded. i don't think fans like the patient center and oklahoma are going to do anything to solve the problems of primary care unless there is a transformation of the primary-care workday and that is going to require fundamental change pat systems. uniques and is in neither context here is edward coming downstairs on the back of his head behind christopher robin. it is as far as he knows the only way of coming downstairs but sometimes he feels there is another way if only he could stop bumping for a moment and think of it. that is how i felt for 20 years in primary care and i think it is the way that most of the physicians deal. the understand things are not right and every day it's like going through war and there's all the chaos of war but really you don't have much time to think about it even if you could and could come up with solutions it wouldn't matter because of the way that you are paid and constraints on what you can do. if you want to do all of the good things that the rich parents group as you do them for free on your own time is basically the way it is in your kids grow up without a that home. so just for a quick background i would say there are two components of the patients entered medical home. one is the old-fashioned primary care, the kind of things that susan mengin first contact comprehensive and so once and for the image always have of the position which is if you don't have one like that it would be good to get one. but then there's the kind new notion of much more about i.t. to take protective care and an organized way of the population and practice not just to happen to show up in front of you and paul were in front of you but all of the basis of the time. but it is transformation i am talking about. most physicians see at least 25 patients a day and some see more than that. but i would say that the majority of those visits are a necessary as face-to-face visits. there are high volumes of upper respiratory infections, low back pain, routine checks for high blood pressure or diabetes or other chronic diseases. much of this could be handled over the phone and by e-mail and some of it or why by other methods. some of it doesn't need physicians but as it is the only way to get paid is for doing these visits and so you just bring them out as fast as you can do. some of it is called hamster care and i would say probably eight to ten patients a day is all a physician needs to see face-to-face. that is basically patience of the first visit or the of complex problems or emotional problems or there is something that needs to be done physically. something needs to be examined, listen to the hard for some reason or therapeutically need to inject the trend. i don't think people don't need to take off work they don't need a babysitter or a nanny and lewis have to dig into the doctor's office. so how would physicians spend the rest of their time? they were suspended in e-mail and phone communications with other health care workers coordinating care and thinking a little bit and then working with the practiced staff to print all of these mice patient medical home concepts into action. this is not a new idea by the way. many people have said this before me but it gets very little attention and i've actually reviewed many articles about the patient centered medical homes say or the chronic care model also they all -- if you read them and think this has to be the way it is almost never is explicitly said that the private care physicians dtc face-to-face better care of the patients. so why give talks about the medical home to the practicing physicians that come up to me afterwards very sincerely and say this looks great we wish we could do this but we are already working ten, 12 was a day and this would add more to do. how can we do that? so, the thing for the patient centered medical home to change and for primary care to be viable way to function in the future and take care of the newly insured patient that a