Satisfaction with the directors of mayo clinic arizona and peter sinai how, a forum hosted by pepperdine university. This is an hour and 20 minutes. [applause] i often get us as sidekicks, four dogs, how do you do it . How do you do that job and travel and the only time i sleep is when i travel, so thats how i do it. Thank you am a kerry for the gracious introduction and steve, and circuit in us all fired up and ready to take on the topic im honored to to be with you today as a pepperdine grad. Ill admit i came for the beach, but a state in southern california, originally from boston because i is such a great experience at the school and im going to reference today the things ive learned and used in a business. I was very excited to be invited to moderate this panel about the future of health care because it is something i think about in my business every single day. And i think about value and Health Care Every single minute. The reason it is because i lead an organization helping to transform value on both sides of the economic equation and health care. On the supply side, we help hospitals, all different settings of care come together to organize tubule to deliver clinically consistent outcomes and help with patient seamlessly through the system. On the demand side, big part of our client base or large purchasers of health care. We work with unions, large employers, some government and they are looking at value a little bit differently. I think when im talking to my supplyside clients, the hospitals, theres a lot of conversation around science can and making sure we can show weve got the best outcomes. I frankly the demand side from the purchases would rather their people and never went to the supply side in the first place. Theres lot of conversation on how we keep people healthy, keep people engaged, what do we do to reduce the Disease Burden before require some sort of episode of care. Weve learned over the years and has been outed in the program, you can see when i graduated from pepperdine. I learned over 27 years and health care that it really is local and that is true for the value and health care as well. What is right for one whole system, one geography, one population, one marketplace is not going to be right, exactly the same across the entire continuum of her country. Theyre certain capabilities needed, which well talk about how you use data, you create incentives to know how you reach out to people and engage them. But what strategy is right for you, you are given a marketplace, be very specific to who you are, what your assets are, which are service client, your place in the market, with two pair landscape . What socioeconomics of the environment you are serving . All of that place and your strategy. It is really important that you think about clinically how to drive better outcomes, that you understand the Business Impact of all of those factors and developing your value strategy. The 27 years ago, when i had a professor at pepperdine, a finance professor got me a job helping model alternative payment models. It was during capitation for a staff model in the sand or nano valley. And i was struck and completely hooked by how quickly when the incentives were changed so that providers are paid to drive outcome, they organized and drove it and they drove it really well. More examples similar to what we were doing at that time. Stayed in that role, but cannot alternative payment models over the past 20 years and finally the aca has passed and we are starting to see an understanding that these things are needed. Everything zeke was talking about. Lots of unexpected partnerships, hospitals and payers going to dinner. Consumers. I think the conversation around the country is really, really interesting because you see true anger. People are passed at these town halls and you have people that really, really want that coverage and people who feel like the coverage is just so expensive. There is fear on all sides. One cannot always make sure i keep an friend of of mine with my staff is that the number one cause of personal bankruptcy in this country is the health of it. I think we have this real or not upon us to try and take her out not just that we take care of peoples clinical problems, but how we take care of the whole community as well as their clinical settings. Up until now, value has been very squarely focused in terms of the programs you see coming out of the federal and state programs on the settings and hospitals having to do something differently. But we now know that macro coming outcome of the first time the federal government is saying we will pay individual physicians based on outcomes as well. So at a pivotal moment, how we aligned, how to support physicians, to be able to perform under these programs is really critical. Moving forward to introducing our two panelists, i think there is a lot of change. One thing i think we all agree on is theres really no turning back. Use of data, the power to coordinate, to create value has left the station regardless of what happens but how health care is finance ultimately. We now know the power of being able to drive value. Okay, so i am privileged to introduce dr. Wyatt decker, ceo at the mayo clinic in arizona and mr. Tom priselac, cbo ceo at cedarssinai. He served as chief executive officer at mayo clinic in arizona and is a Vice President for the mayo clinic since 2011. Hes been with mayo clinic for more than 16 years as a consultant and emergency medicine for the college of medicine. He served in numerous leadership roles, including chair of the Mayo Clinic Department of emergency medicine from 2000 2008, with responsibilities for the Emergency Department at mayo clinic in rochester, minnesota and jacksonville, florida. Please join me in welcoming dr. Ducker. [applause] mr. Tom priselac has been the chief executive officer and president of the Medical Center since january 1994. Hes been associated with the Organization Since 1979. Thomas on executive staff of the hospital prior to joining cedarssinai. He currently serves as past chairman of the American HospitalAssociation Board of trustees and pastor of the American Association of medical colleges. Please welcome him tom. [applause] okay. I will ask both of you gentlemen to kick off with a few opening comments. Why, do you want to start . You might start . You might think, make them. I would like to thank our host megyn herself, but also her colleagues at pepperdine and giving the opportunity to join today. Its really a pleasure. So, we have started the day with a fascinating conversation on some of the nuances of health care, but also an overview that i think challenged us to think about the expenditures of health care and quality of care in the United States. One thing we hear a lot about is how that health care is in the United States. But for some of us that doesnt quite tell the whole picture. I would like to start with a little thought exercise. You or a loved one has been diagnosed with an incredibly serious condition trade maybe its a rare nerve and youve got to get care and you need to get care soon. How many of you are going to book a flight to some other country because you can go anywhere in the world in this thought exercise, are going to book a flight to a different country to get medical care there. Anybody in the audience . Usually theres one or two because countries have much looser oversight, so 10 times people will go overseas for that. In fact, the United States actually enjoys some of the best Health Outcomes for complex conditions, including things like breast cancer, colon cancer, Prostate Cancer in the world. So while we have an incredibly expensive and it times fragmented system, theres pieces of the system that are really working well. I think that is sent in by the National Conversation about health care, quality and outcomes are local conversations, that is something we dont want to forget and we need to actually enhance. We want excellent and health care. The mayo clinic, one of the things we have been saying is where is the voice of the patient and all this National Conversation about how to Reform Health care . I mayo clinic we take care of 1. 3 million unique patients from every country in this union and 140 other countries who do fly to this country for their care every year. Here are some of the things that we hear from our patients. They want access to care. They want access to centers of excellence. They want coordinated care. They dont just want excellent. They want excellence where their team talks to each other and they want integrated health care. Of course they not only one access, but they Want Health Care that is affordable. Heres a rather quick thought exercise. Is it always necessary is excellent and good outcomes always more expensive . Anybody . No, it doesnt have to be. Many of you are Business People and you know that the secret behind the solution to a problem where you want excellent quality and you want affordability is innovation. We need the ability and health care in the United States to innovate and that is something that you are going to be hearing from today. Cedar cyanide are dried cedarssinai. We heard a little bit about the price of colonoscopy as an example of not only price variability, but also kind of an eye popper when you say those could be screening colonoscopy is good in this country of 49,000 patients try ever your colon cancer. As the secondleading cause of cancer in the United States. A third to a quarter of all eligible people dont get screening colonoscopy is. I dont know why. I had when it was great. Who doesnt want to colonoscopy . [laughter] but what if instead what if instead of haggling over the price of colonoscopy, and Innovative Team came up with a totally different solution. A totally different solution involves screening for micro amounts of dna in your store so you dont even have to have the colonoscopy. That technology was developed over 10 years at the mayo clinic, published in clinical trials, approved by the fda. It was licensed to a company that is now offering a test called cola garden i have no financial stake in them, but the Important Message is that is of course a fraction of the price of colonoscopy. It increases access grinning, can result in better care at a lower price. I share that with u. S. And example of how powerful innovation is and how critical it is the Donation Centers of excellence not only continue, but actually we figure out how to help them first so we can invest in our nations future so it can work. Thank you very much. [applause] banks. That was extremely well said. I want to think pepperdine itself or in my case inviting me back. Its always nice to be invited back. When kerry asked me, i said yes because i think this actually is one of the best health care discussions of this type, at least that occurs here in los angeles in this region. They appreciate being part of it. A minute on cedarssinai. I say that and i want to do it for two reasons. One, im a believer in where you stand depends on where you sit, but also i think it does provide context for the rest of the discussion about the whole question of value. Very briefly, cedarssinai is a private notforprofit Health Care Organization that has a fourpart mission. Patient care both in the inpatient, but extensive outpatient side of things. Medical research not unlike described the mayo clinic connects medical education for graduate medical education, undergraduate nurses, et cetera and an Extensive Community benefit and Community Service mission. We are downturn last 2000 physicians associated with cedarssinai. Relevant to the later discussion, about half of those physicians are what i would call tightly integrated with cedarssinai. The other half are in private practice in the community in one way, shape or form. Cedarssinaiprograms that make make him a joint venture among ourselves in the ucla and rehabilitation institute, recently opened here in los angeles. Multiple ambulatory facilities in the area. We have been to be the largest hospital in the western United States, but as we try to emphasize, its not about being the biggest, its the best. That is what we really strive to do. It is a combination of what you might call a Community Hospital in our case for the Community Hospital for two to 3 Million People who lived in the los angeles area. We are also the largest provider of tertiary quaternary Services Come at the most dance treatment in heart disease, cancer, organ transplant, neurosciences, highrisk obstetrics of any hospital in california. So with the combination of the two of those things. In terms of our patient mix, about 40 of our patients are medicare patient, which makes us, by the way, the largest provider of Medicare Services in the state of california by almost a factor of two for any individual half ago. About a third of them are dual eligible. For those of you dont know the term, those are individuals who are both elderly and poor. Also one of the largest providers among private hospitals in the state of medical services which gets to the commercial insurance that we will touch on a little later. My point is what we do and who we serve as a Significant Impact on both how did they scare affects us, but more importantly how we are contributing to that movement. Very quickly, definition of terms from a personal standpoint. Valuebased care is all about providing the appropriate the best outcome for the patient in a high safeway at an affordable price and in the most Cost Effective way that we as an institution, given what we do and who we serve can provide. This is something that we are firmly committed to as an organization. Wrinkly, to start because we believe it is a professional and ethical imperative for the organization, but for all but for all the recent geek outlined in his opening remarks, as an economic imperative for the country in many, many ways. I would observe and am listening to seek actually it really reminded me that california actually has been in this valuebased care team are really quite some time. I think it is fair to say more so than the rest of the country in one way, shape or form having been in california and 79, going back to the mid80s and moving on from there. The Affordable Care act certainly turbocharged the movement to valuebased care. Frankly, in the way that only big movement by the federal government can when it comes to issues Like Health Care in america, given the role that the federal government plays in this arena. The American Health care act, which is i guess perhaps being voted on or has been as we speak. I think frankly has elements to it there is question about the momentum around that maybe we can touch on that later on. Finally, you know, when i think about valuebased care, a think about it in three ways. This valuebased care of the patient level along the lines of what wyatt and i already described. Theres the issue of value they scare the Organization Model and there is the issue of a valuebased Health Care System as it relates to the system is held. Whether that is at the regional level, state level or nationally. Most of the work to date i think has been on the first piece of bad with regard to the patients level and appropriately so. I think to get to what zeke was describing in terms of solving the differential between american and other countries at least on the con side, and the issue of valuebased care at the patient level is necessary, but not sufficient to complete a journey without also examining those other two elements. I think that the movement to valuebased care and be diluted to this as well is fundamentally connected to having organized systems of care, organizations and structures that have the capital and have Good Management capability to bring to bear the kind of change that is involved in moving the country from where we are to the future. That conversation, by the way oftentimes breaks down into a debate about hospitalbased systems are a physician driven system. Frankly, i think that is a waste of time. Lets get on with figuring out multiple examples around the country of organizations that have their roots in physician organization. Mayo clinic is a great example. Organizations that have their roots in the hospital side. Organizations that have their roots on the payer side. Here in california, kaiser being an example of that which frankly started as an Insurance Company as many of you know. Last comment is with regard to this question of valuebased care, with regard to both measuring with regard to measuring quality but in particular efficiency. I think we are very early on in that journey and among the things that hopefully will be addressing in the years to come are the Measurement System themselves. Thank you. Thank you both. [applause] so what we would like to do today is take a little bit further into some of the concepts they were just discussed. Alaska series of conversations to prompt the conversation. Specifically, there is some conversation right now around the definition of fee for value. We can see high level we are moving towards it. In their organizations either one of