The physician community, the american of the American College of physicians, for example, does not represent its leadership but not necessarily represent its membership. Whoe are Health Economists think the problem is not utilization, but the problem is prices him and it is not physician prices, it is at least under medicare it is prices of images, drugs, tests, the three we haveaccelerators in washington. None of these proposals do anything about that. By the time your proposals again, the accelerators are here and who is going to pay for them . That will be loved into what ever fees are charged, bundled, or otherwise. Bundled intobe whatever fees are charged or otherwise. That is an important point that we looked at a specified set of comprehensive proposals that certainly do not represent the totality of all of the ideas out there right now. I do want to clarify, though, and say i do not think that the proposals were limited to looking at limiting utilization, and i think in fact, that is a criteria for selection of the proposals that we looked at. We did not talk about all the provisions, but i think another key element that was in many of the proposals was a focus on beneficiary engagement. That is different than having gettingthe game, beneficiaries really engaged and giving them more choice. In fact, there is a significant agreement among even some pretty abstantial proposals in to different medicaretype benefit package. I want to clarify it is not just all about limiting utilization among the proposals that we selected. Ok, the other side. Hi, National Coalition on think thee and i Commonwealth Fund and the alliance for doing this. I wanted to return to a point that i think both paul and len made and sheila different a little bit about the notion wouldnt it be great if the sgr reform was part of a broader agreement, closer to a grand bargain, brought entitlement reform brought entitlement reform . I wanted to attack that a little bit. Would it be possible, given where we are at now, we come to march, and for lack of that if folks kind of back away from attempting to do sgr now and pay for it in smart ways, wouldnt we undermine that kind of confidencebuilding effect that that would have . I would like to tease that point out a little bit, from the folks. You do not want to have misunderstand. I mean, it would have been great had a grand bargain been available and if agreement had been reached on a whole variety of things rather than a relatively limited package that has moved to the house and is about to move through the senate and a separate sort of sgr conversations that will continue into next year. No question, a great many of us on both sides of the aisle had hoped that we would have a much larger conversation, certainly reflected in simpsonbowles, perfected in the work that paul and i were involved in at the bpc and other places, the presumption that the best scenario is the one that looks at this in a much broader context. My reaction was simply that i guess too many years on the senate staff said that incremental is not always a bad thing. Sometimes the opportunity to begin the conversation and make itself to as lends broader conversation. I think what it did was allowed people to come back together and Work Together in a bipartisan not seen that. I do not recall the last time the finance committee at a markup, but it has been quite some time. In talking to some of the staff and saying onto looking forward to it and a say i have never been to remarkable for, it was an interesting six prints. Three or four years. If it does nothing more than get people get back to the table, get the sass working together, what i understood was a collaboration, both on the senate and the house sides, i think there is an opportunity there. Yes, would it have been great to get a grand bargain . Want toly, but i do not suggest that what was done was not in fact important and in fact lends itself to a broader conversation. If i could say one thing. What i was referring to is really doing and sgr fix on its own, it seems the pay force have ors have tothe payf come for medicare. Whereas if you do it more a fix. , there is fors are easier if you have a context. I would second the point that learning to do bipartisan, even at a birthday party, is a really good idea. Will turn to this question here, and then we will go to a question that came in on twitter. I want to remind our cspan viewers that they can submit questions to us via twitter at ostconsensus or a twitter healthreform. One of the things we have talked about is a shift of paying from autumn to quality and value. One of the levers is quality measurement. I am a big fan of this. It is admittedly a science in its infancy, and some of the implementation has been a little less than ideal, and there has been a big pushback from from positions in prayer the writers. Im concerned, are we creating a generation of physicians who are alienated from these sorts of repurchase the quality measurements and performance . I can answer part of that question. What i have seen over the last couple of years is a tension between measuring quality or value at the level of a Provider Organization versus the level of an individual clinician. I heard a lot of these approaches are in never going to work. At the level of individual clinician. I am concerned with the attempt to try to do that. For me, i think the focus should be to encourage the development of organizations that can take on these responsibilities because we are never going to be able to build a direct incentives into the Medicare Program for individual clinicians that makes sense to them. I would just add that i agree with the individual physician versus group point that paul made, but i would add that there is a difference between ensuring quality for a clinician to continuously improve their organizations performance in measuring quality for the purpose of computing value as we are talking about in these contexts. The dream, of course, is for you all to inform the idiots making the payment am right, and that is why you had a process. I think what all our proposals call for i think, at least one that mentioned it, was more standardization, alignment, i believe is a nice phrase rachel used, but a standardization of the Quality Metrics being required. I know an integrated system in virginia that is producing Something Like 249 quality measures or different i do not know what the right number is. It is not to 49. I think you got to have this process, but you got to start. We cannot feed paralyzed by the absence of perfection, and you know this, and so we will go from there. One final addition. The other thing that has changed is that more people now talking about not just the measure of quality, yes or no, but having a more informed conversation about how is the data going to be used, and it is very different to get providers on board, and there are some things that people are comfortable using, quality out forms to make palin decisions, and there are some things you know as you make care decisions with the patient. So i think there is a more sophisticated conversation going on right now about quality measurements, aligning those, but also before you are just collecting measures to collect measures, what are they going to be used for from and this understanding that not everything needs to be tied to benefit decisionmaking. I want to underscore the point and i agree with richer. There is a more collocated question today and a more nuanced one. In all the proposals commensurately the work that we did at bpc, there is a sensitivity to the indicators that people breathe asked to track. The cost and the word in on individual providers as well as on the systems, the desire to essentially simplify the process am a make it rich, but make it appropriate and morse and the guy said we cant agree on the uniformity or at least some kind of consistency that providers systemsrunning multiple and the burden of that. There is absolutely. Nqf isho is now running invested in understanding cap and developing criteria can be best allies. There is a conversation taking place that touches on a very important issue you have raised. Ok, from twitter one provider payment reform that could be instituted that would demonstrate a shift away from the for service . I would ask the panel to give us a sense of the level of consensus on this one provider reform, payment reform. , i cant one thing i want to bring up is in the bpc report, there is a simple thing that providers that are part of and the Medicare Network or have episode bundling contracts yet higher payment rates. A big difference. That was great. That was i was going to say as well. There are commonalities among the proposals about weve been talking about the sgrs. Exempting providers from a threshold per my threshold amount, 25 , of their asian practice, and these new provider arraignments, primary medical homes, exempting them from the sgr freezes or scheduled physician payment rates that happened under sgr repeal. That is one element that sticks out. All the proposals address that in some way. They did not all agree on the level or for how many years, but they addressed how you deal with medicare providers. I think it is interesting that both of my very learned colleagues immediately talked about increasing fee for service for the good guys. It shows you how hard this is to move the ball really fall really fast. I will go out little farther on the limb and say some kind i do not know exactly what kind but some kind of pmpm to providers who are willing to demonstrate they can do coordination for all the good offf, and there is a start that in a kind of a cumbersome way in the enc on a bipartisan basis, and the senate has a version where they can play pmpm s for being certified. Thaton the board of organization, but i think the idea of rewarding our merry care entities for taking on responsibility what i would like to do is link that to some kind of risk down the road, some kind of performance base. Maybe the thing grows over time if you bear morris. The key thing is eating the clinicians to be aware of the total cost of care. That is really hard to do, believe it or not, in the Current System for most american are. Airs. What most pmphs is show that docs the data, and docs are usually shocked. I did not know that. Hitting the data in the docs ha ays, getting the pathw to the solution and rewarding them for the infrastructure theyre going to have to build, that seems something worth voting. I will say the evidence on pcm ih is not thrilling. Costd evidence pretty evidence pretty mixed right. We have not designed the perfect a bee. That is what i would say medicare could do with a little more oomph. Thank you. We have a question. A couple questions, actually, addressed to paul, if you would not mind kicking us off on this, and then sheila and len, if you could respond. This is a much broader cover station than cover station then we have time to get into today. What do you think is going on with this Health Care Spending growth slowdown . Is it real, is it going to continue, and how much of it can we attribute to potentially systematic changes coming out of butbly not thea aca, the systematic changes at that level . That was a very tough question. For everything i have read and from panels i have into, i have been to, clearly the recession and its aftermath was a very large factor in this, and hopefully that will go away over time. I say hopefully because hopefully the economy will come back. There doesnt to be some evidence of some structural changes there does seem to be evidence of some structural changes that need to be made. Not the acos. What people look that when looking at acos, they are not saving a ton of money. There is evidence about how technological change has slowed down, and as it has slowed down because it is running and has things to do, or because of the recession, because the market is not there . I think some things we are going economy isonce the restored, is we are still going to have a much more payment of the point of service by paid patients, we will have incentives to use provider some more than others, there is a lot that is going to be continuing in a stronger economy, and i think that will have an effect. Ofi am optimistic that some the slowdown in spending will be butned and probably probably will not be as extreme as it has been in recent years. I think it is fascinating to observe that the slowdown actually began a couple of years in 2007, for the recession really hit. Contributedecession to it, no question, but it already started. So what is the deal here, and what has continued . Were speculating here, so i would just say in my opinion it has to do with the fact that a Critical Mass of health care decisionmakers had figured out we got to do something about our Health Care Systems costs. I start with employers sending the signal, sending the signal that we got to find cheaper ways to do this. Hospital leaders i have never seen Hospital Leaders unanimous in being aligned around this point. We got to reduce cost. Before the aca. What the aca did was kick in and turbocharge it and really down a marker. We are not going back. Let me tell you a secret ash real. Pdate reduction is it takes learning out of hospitals forever, basically, at an increasing rate over time. That aint changing. The penalty on readmissions, which gets worse over time, these things have focused the minds like never before. There has been a systemwide ok, they are serious this time, and some of that is going on. I think everything paul said is right. I think the technology think maybe as important in the short run as anything else. I think it is both, a, nation of all things that have then touched on. There will be elements, that will be sustained. We are also looking in terms of the aggregate at this bubble of baby boomers that are coming to the system that will certainly put enormous pressure on the system. Many of the elements that were contained in early work in the sensitivity and the sensitivity on the part of players of employers and others about that is not going to go away come and many of those kinds of changes will be sustained. The good of this microphone. Ok, lets go to this crime. Ma media. What we know about increased costs for emergency care, also for delayed treatment of known and medical concerns and conditions . Can we make comparisons with the solar Health Care Costs and other nations . Ownnt to mention in my personal medical experts this year, i got a referral in august from my general practitioner. I was not able to get an appointment with a specialist until the end of november. Then when i needed to be treated in september, they told me to go to the emergency room. That had to be more expensive, i think. I made to a more jazzy room visits in september as i made two emergency room visits is ever as a result of that. I do not know if we know anything more in terms of what youre asking than we have known for quite a long time. Ishink what is fascinating part of your store is when you look at and maybe i am if you look at what physician groups have to do to qualify for the private cmhs, whichned p are by far the largest number, the first thing they have to do is figure out a way to give 24 seven access, and it could be that they have to have a nurse on call and call them whatever, but they have to find a way to address the question of a human theg who needs care outside nine to five situation. That is a precondition for been the payment bump up whatever you get to join the program. Weis unambiguously true that have learnt because payers are 7illing to pay for it that 24 access has a costreducing effect. It also has a beneficiary having this effect because youre not just off if you do not have to wait and all that stuff. Those things are holding consumers in their. We know going to the er, when need, isot k ridiculous. All that has been known for quite some time. I do not think anything new is there to learn. You asked about international comparisons. We know we are paying more than any other industrialized country for health care in total and per have, and americans are more likely to go to the emergency room room because they do not have access to the usual source of care that anywhere else in the country. Have good emergency room metrics. One thing that i thought that might be a factor is the distortion in our fee schedule. The fact that we pay so much. More generously for procedures than four visits. That may have something to do with you having to wait months for a visit with a specialist. Will take exception to that as a specialist, if i may. Go ahead. I do not want respond to that question, but i will. Three or four months is ridiculous, i will agree with him, but i do not think the difference in pay has anything to do because specialists are overrun just like anybody else trying to do clicks. There is much a shortage of specialists as our primary care. One of the other things before we jump on the primary care bandwagon, look at the training of the primary care docs now compared to them 20 years ago. Len as an antidote, and knows this, before i left washington i looked at who was coming into our clinic, and over a fiveyear. Period, we had a 300 growth in patients with functional disease that should have been cared for by the primary care. Why did we have to see that 200 increase which ends up delaying the patient with real disease coming in . Before we get into this, remember we have to get down and look at a few other things, and i will segue into my question a few other things is training. You got to look at training, of how they are being trained. Second, it took us an hour and a half into this program before rachel tensioned data that len mentioned four more times, paul alluded to transparency, but without the data, why do we do it . Comment about doing a Manhattan Project is great. Being tovided in this, get schizophrenic being too schizophrenic. Equality aceson of what i did in 2013 and paid in 2015 is like what we are taught not to tell the mothers, say, johnny, you are bad, wait till dad gets home to spank you. You got to put it into the context of when you are doing it. How are we going to have a Manhattan Project . Infrastructuree to get timely data to the physicians so they can make the improvement . I will tell you right now a lot of the associations that are doing the quality measures are starting to say, what is in it . Where is our association . Are stepping back from that. They do not make money for four or five years. I ring that up that l i bring whenup that len said that physicians see the data, they will change. When you get physicians comparing what they do against their peers, locally