Instead of seeing you went to the emergency room. This is not a typical example in this room, but i personally can think of many times when i wanted to see my primary care physician and there was inadequate and available for weeks. Your only option is the emergency room. What would it run in your case . Did she make the case, the system set up wrong case for her . We were available. Broken seven days a week. The weekend of christmas was my weekend to work. We saw 95 patients that weekend. Work seven days a week. We have access to imaging and most of her primary care product is and specialists have that now is a service giving up from studies that decreases the cost of care bulleted to those of extended hours by about 10 . But it really has to be incentivized for what were doing in terms of creating a tepid economic model that is about access that works. In this situation, the patient just wasnt used to it. She caught a friend of hers and said what do you do . In the same thing may have happened at our office, but it wouldve been a different point of entry. We knew we had access to Electronic Medical records and we may not have treated her as aggressively. We do think access is important. I think to Say Something about the terms primary care physician. It was invented by a copay. I used to be a general internist when i was in training and it was about a discipline of study. If you Pay Attention to what they call doctors, its because were getting ready change the way we are paid. Primary care versus specialists had to do with one economic model to control cost in the gatekeeper system and then drgs and then hospitalists are not turn as for those who are lifestyle oriented at night. [laughter] specializing to Pay Attention because they changed the names again. Theyre being called procedure list. That means for getting ready to get whacked. In the context of how we talk about those who care for us, a lot of times this economic language underneath. We talk about concierge medicine, that you has to do to assiduity Payment System as opposed to a care system. I dont own particular the term primary care physician is such a bad name because primera to be a good thing, but it wasnt something i even heard training 20 years ago, but the time i was out and look in a copay differential, thats for the term cannot had to do with the Payment System. I dont know what the solution is, do we need to Pay Attention to what we call doctors or their care providers because underneath is quite often an economic assumption. Im wondering how guilty billing codes are for a lot of what is going on. Should the whole system be revamped or wiped out . When you think how many different codes, 10,000 . Its anon believable number. In terms of Discrete Service is, which isnt what anybody anybody wants, right . Let me give you great example of the problem this creates. If you think about i use primary care because theres a great area of being chastised. Ill put myself at risk and use it anyways. If you think about primary care in the work and what the patient needs, it seems pretty obvious to me that a great body of support for that work would be nursing. Nurses to great primary care and theres data to suggest people treated by nurses are healthy. If thats the case then, why isnt there a greater proportion of primary care delivered not by Nurse Practitioners, but nurses . Its not credible to me that its a competency question because if you go to the hospital intensive care unit, nurses to lots of care for various patients and they do it well, so why not . The answer is its impossible in many cases to fit what nurses do into billing codes so you can get paid for it. What you pay for you get and weve got a system that has evolved that has been responsive for what we paid for. If youre going to move from a transactionbased system, in my opinion, to a longitudinal care model of primary care, then you have to move away from transactionbased payment and discrete payment and moved to budgeted payments, longitudinal payments to take care of patients for a period of time without regard to what the billing for the individual service is u. K. And then let providers,. Yours, nurses and others and that they how they approach care of their patients without the shackles of being limited by what billing codes well and will not allow for in my opinion. Any outcomes that appear in washington because i cant find anyone with these ideas to go to when i go to see my doctor. I think thats part of the problem, patients are frustrated. If you see a good model, you dont know where you can access the model where you live. Part of that is really communication between the providing organization, providing doctor or nurse. When we went to seven days a week urgent care clinics open until 8 00 at night, it was three years before we got her patients to understand we were there. W00t for science in the waiting rooms. We send out newsletters, stuffed in the billing envelopes and so people would say are open on weekends . I didnt know that. So a lot of it is communication. I cant emphasize enough the access, particularly in 2013, we are used to the iphone and instant access to everything. If you wait for the 25 seconds, youre annoyed. I think you think thats true if you call up your Physicians Office and either they dont answer the phone or the answer the phone late or they say we have an appointment two weeks what to say, theyre going to say and appropriately, im going to get it someplace else. Its incumbent on the Delivery System to respond in a culturally appropriate manner and 2013 and offer services when people want and peer thats not always easy to do, but something we have to do on the delivery site to make that work. I just want to make one little comment about the nurses delivering primary care. We have a number of nurses and nurse for dictionaries to operate in our Diabetes Initiative with diabetes educators to do a spectacular job. I would make a pitch however for the doctor when someone walks into the office and says i hurt, i got a pain in my belly gourmet had that feel right, having gone to medical school, not only does that add a quality site, better experience with our physicians tend to utilize the expensive ancillary services somewhat less. Thats been our experience, too. And just to follow up, i agree completely. By the same token everyday part is, theres not a status bar routine that is not diagnostic in nature. Ongoing maintenance of uncomplicated diabetics and so forth to talk or staff to do. Our nurses are way better at taking care of people with diabetes than i am. A real practical outcome of being able to organize that way is its an important solution in my opinion to the primary care shortage because a busy primary care doc or, [inaudible] will be a lot to take care if a full panel of 22, 2300 patients depending on engagements and what not. If you organize yourself differently and the others to offload the work, a doctor. Huckabee ambition to go from 2500 to 5000 without crashing a doctor in the process of making everybody happy. But they come every two years early. Were doing a lot of that in our organization and our 367 providers now, well over 100 are midlevel providers. I totally agree our city so far overly fair, overcast relative to a difference in training is something we have to understand and get more portable last for routine care and evidencebased care. But even within the context of all of that, what i think about what i do when im seeing patients, 85 could be done by somebody else. The other 15 is really, really important and what weve got to understand why we change our pay models as we can expand primary care, all sorts of shortages are really having everybody worked to the top of their license. But weve got to understand that that 15 is because its really important. Tardis diagnostic and has to do with things particular to treating physicians have had that others have not had worked hard in different ways. They bring other things to the table. The piece we do have is extremely important to the real issue is everybody doing the right thing and the right place. I think we can. Its going to be global payment, making providers take risk and that will get us all out of fire business. We can open up a little to question. Theres quite a few questions here. Its when you ask a question hell stand and say who you are, remember if youre watching on the web, send questions and assault. Thank you. [inaudible] [laughter] even in a small country as the netherlands, with all kinds of examples of good procedures and practices. The issue is how to spread throughout the system so the system changes. I like to ask a question two. Your murphy. This is a completely different magnitude, but at d. C. For major changes which you are talking about . With medicare need to be changed and made her way . Pc animation doing such things . I see it as a combination of two things brought up and discussed by the Previous Panel and theyre both necessary conditions. You need to have a map, aslan was talking about, some roadmap for innovators have mapped out about sunland in place and some pathway to get there so that its not offering a deal. The everything you need need in my opinion is its hard to happen spontaneously without Strong Financial incentives needed to do so. As humans, we are creatures of the status quo. We can ensure comfort sounds and tend to like it. As long as people perceive the status quo as Practical Alternatives and thats generally things that are coincidently continuing to do the work and well see what happens if a retired to someone else. As long as someone sees the status quo as a practical alternative, its going to be hard to see change. One of the suggestions brought up earlier, i forget by whom this will have two fixes. Well have 68, a little fix that you feel squeezed about and thats if you want the status quo. On the other hand, if you want to move into a new Practice Model for product this differently, as they were sensitive fix that you would be the beneficiary of that would facilitate your movement out of your comfort zone into some other place. Im quick to say thats not a wellthoughtout policy formula rather than just a notional direction, but she needed endpoint that make sense to people and networks with data and you need Strong Financial incentives to encourage. Just a quick comment on that, the aggregation mentioned earlier in the panel is part and parcel that you have to give providers together in a large group is very difficult to do. You really cant do that. Secondly, once you get people together in a large group, you need to have the group be nimble. Large parts of our health care Delivery System or not nimble, where change is ponderous, iraq receives difficult to cut your way through. In order for innovation to occur and change to occur, you need people to move relatively quickly in a timely manner and unique to the data data in a timely manner and all those things are intertwined. [inaudible] im not sure i agree with that. Terror groups like yours and in our case were not huge. Her 75 doctors in another 50 ancillary care providers. We were able to make decisions because we have a relatively small cadre of people who can make decisions and move the group in a different direction. We have a great relationship with hospitals and towns away lovett are more closely, but to get decisions at a hospital is a much different process because theres a lot of different stitches and sees served in those places. Its hard to miss that type of organization rather than an organization focused on a mission. If were going to be having a system from the one of the big risks we have right now is they tend to have the capital out there, so they tend to be the aggregator physicians and other services that many people think that model is that linksys to the future. The issue of nimbleness is extraordinary and a lot has do with the high fixed costs. Theyve got to feed the beast and until we figure out some and quite disruptive to that, i dont think you can have anything adequate to where we need to go for a Sustainable Health system. Having said that, North Carolina the largest employer in most towns as the hospital. Looking to invest in education and other things. Right now we stand for much of afghanistan or put them in jail is working for a hospital. If we move, we have to understand its not going to be just lobbying related to complaints from insurance and mr. Hospitaler physicians or whomever. Its big, disruptive, economic repercussions with what we can reconstruct this industry has lived across the seas. With all investments in health care we havent had time to invest in anything else. But as we divest and change in mr. That model, its a far deeper economic problem that even just the Health Care System. Its deeply rooted and everything for the last 50 years. One more question over here and that i will have time for. Edward ryder from sunshine press. I read about Interest Groups in washington and looking at health care, seems analogous to the other american is dictation that is failing compared to other oecd and that is education. In los angeles and some other cities, teachers are rebelling the nea and its fixation [inaudible] nea as a unit. Theyre interested in in quality education. Theres been no talk of any incentive for doctors other than cash, but lots and lots of physicians take positions that pay less because theyre motivated. By primary care physicians. I agree with that completely. I think that doctors go into medicine for the right reasons. Might it not be worthwhile to come up with reforms for doctors or groups of. Yours that were performance other than what cash . I think a lot of doctors are taking jobs as opposed to small practice opportunities, largely for that reason. I think its easy to come in to a basic for them. At the same token we need to make it financially practical for them to pursue the, which is at least how i look at it. I dont have to send my kids to college. Dont worry, ill just do good work. You need to have a sustainable Economic System consistent with chasing the bigger engine. And about what the doctor assess a person who didnt go to a frat party stated this i krebs cycle would happen when they were 35 years old or older. Its a model based on delay gratification. So at the end of that you have physicians of the hundred 60,000 in debt and their spouse if they have one ready for the big payoff, status going down. Economic uncertainty. We were selected for medical school because we liked risk. We were selected to medical school because we are riskaverse and general as a profession or model into a period when you say what could motivate folks coming have to think about physicians. You have to get to the better nature. Its got to be about the patience of my luminaire. Youd also have to think about the money. If you have a system thats going to be physician led in debt than they are still think the the ability do it in a way when they make the screen are again with a society now changed 20 years after they made it in stating to do that krebs cycle, youve got another thing coming. Once you got that right, youll get what you want to do because its incredibly exciting now my organization when we say we have added business in three years are made done it. During the next three years are going to give you a guaranteed salary and they want to change everything. Its not a high salary, but we want to change everything to do the right thing in quality. It has changed everything in our group in terms of our physician behavior. I think many groups including ours are moving to compensation systems that are at least partially based on quality. We are living also in a world where the rabbit will other route will or product to the wheels this part of the system we deal with. What weve done is to change our compensation system so a percentage of our Physicians Compensation is based on Quality Metrics and eventually are going to have Quality Metrics and Patient Satisfaction to a much larger percentage, which is to some extent what youre talking about. [inaudible] which is a wonderful thought. Im so sorry, but weve run out of time on this panel. Id like to thank dr. Claffey, dr. Murphy, dr. Terrell. Tokamak our next panel take apart everything up to now and add some thoughts as well. Once again, thank you for distinguished group of panels weve had. Give them another round of applause. Really to create panels. I now invite you to save her third and final panel will be coming around handheld microphones for the panel of experts q a portion. We encourage you to use our twitter hash tag mj medicare. Joining maggie on stage now we have dr. Juliette cubanski come associate Director Program in medicare policy at Kaiser Family foundation. Debbie curtis, professional soccer housemaid mean, jay cost has helped counsel the senate i nantz committee. Megan mccarthy, policy analyst and former National Journal health care and dr. Dana safran of measurement and improvement of Blue Cross Blue Shield of massachusetts. I think we have everybody. Alternate back to you. Thank you very much. This is the juicy panel because were going to take all these ideas and translate them into how we can actually implement them, we can actually do given the political reality in washington, given the current situation. I think everybody here i can see you responding in the audience. I also want to make one important statement that these thinkers are not just academics. Dr. Nichols is still here, listening to the real people talk. I see dr. Ginsburg were here. They just left, so we know everybody is listening to each other. The reality is that arming the academic thought as well. Its important to note washington because sometimes you think people are disconnected from one another. Here on this panel i hope you all can bring it all together. First of all, i think we can just start off, do you have any immediate thoughts and what you heard today . Jjuliett, y