thank you. can you hear me? thank you very much. i'm going to start off with a disclosure, which i -- is on my front slide. i want everyone to know i will talk about home based primary care, a house call clinical model for elders and how that led to the independence at home. my disclosure is, my presentation does not involve cms sponsored analyses. it's my responsibility and no review or verification by them. hopefully, patrick will be okay with it. next slide. i'm going to talk first about the patients that we serve. i would like to do a brief survey of the room. how many people in this room have an elder in their life who is sick and has trouble getting to the doctor's office? raise your hand. looks like more than half the room. independence at home and home-based primary care is the model of care for those people. 17 years ago, dr. george toller and i came to d.c. and decided to set up a clinical model for care for those who are frail and have trouble getting to the office. a house call program but more than that. a home-based primary care program that would follow them across all settings. we'll talk more about the details. we wanted to look at the effect of that kind of model, a mobile team-based approach to care in the home on quality of care, the patient's experience and ultimately the costs of care. which is i would say a secondary outcome. most importantly, what is the impact on the patient and the family? we will talk about some of those results. then i want to close with talking about what's next. how can allies and policy makers both here in this room and across the city help us expand this program? so who are the patients? it's actually a highly targeted clinical service. in contrast to some of the other demos, it targets less than 5% of the medicare population. roughly 2 million of the medicare population could be eligible if it was expanded nationwide. our practice, they age 66 to 110. the 110-year-old just recently passed away. she was born on january 1, 1900. at the beginning of the century. so this is the kind of folks that we talk care of. this service, the intervention is really simple to describe. hard to execute. it's interdisciplinary mobile primary care teams. 24/7 availability across all clinical settings. it's not just about making house calls. you take care of the patients wherever they are. you coordinate all services that they need, medical services, social services, sub-specialty, transportation, whatever they need. the goal ultimately is to enhance the health and dignity, bring peace of mind to the caregivers and families. those are the two primary goals. happy side effect of this kind of care is that it has a dramatic impact on per capita medicare costs which we will talk about. in a positive way. the independence at home model, which was based on home-base primary care systems across the country, allows home based primary care teams to be scaleable. that's the major take home point for the day. the independence at home both demo and payment model allows it to be scaleable. the reason for that is -- we will talk about more. these are the main points. there's strict criteria for eligible patients. you have to be frail, disabled, have had high costs in the past year. there's a high bar for service quality in the program. you need to have all the researchers in play to take good care of these very complex patients. you only receive savings only after you have achieved 5% reduction in per capita medicare costs. there's no up-front payment to the programs. there's no payment until you have exceeded statistically a greater than 5% reduction. you have to link the savings to six relevant quality metrics that providers would get 80% of savings if they immediate all six quality metrics. this highlights -- it highlights the focus on the top 5%. why that has super a big impact. the orange on the top on left is is the number of beneficiaries. but they expend nearly 50% of the budget. this is similar now in the current medicare medicaid population as well as commercial payers. this is the population you focus on to have the greatest impact on costs. i'm going to talk about a patient. a 69-year-old who had liver and falls and care given burden. the year before she moved to d.c., she had six admissions to the hospital. that's six admissions per patient year. the daughter moved her mom to d.c. in order to gain entry to a program. for last four years, she's received over 150 house calls, many social services, coordination of aid, home x-rays, ekgs, wound care, many urgent visits by our team. had a terminal diagnosis reversed. had a radiology procedure where she was hemorrhage and we thought she was going to die. we used the hospital high level high tech care to do kind of a last minute procedure that worked. she has been home for the last 18 months. in the last 4 1/2 years now, she's had two admissions. she's been four years orlando older and four seeks sicker. she had one e.r. visit in four years. i have to change this. two days ago she had another e.r. visit. i want to say it's two in two years. how does this work? this is say busy slide. i won't read it all other than to say, home based primary care team has to coordinate everything. over time, until the last day of life. we coordinate routine and urgent visits. today from the weekend, we had ten unstable patients. nurse practitioners around d.c. making house calls to prevent emergency room visits and keep people at home. we coordinate e.r. care, subspecialty. we direct hospital care so we can manage the discharge to home. we're available 24/7, as are all of the programs have to have a 24/7 availability. we manage rehab, hospice. the next six are the things you can do at home. what is possible? the hospital really is only for intensive care, surgery, procedures, complex level of things. you can do almost everything else at home. from radiology to blood draws to ekgs to echos to equipment to i.v. as long as you coordinate, you can have a dramatic reduction in costs. this is a quote from sylvia, the daughter of the patient, about how the program saved her mom's life. it restored her faith in the system. the good days, hours and moments she has are a result of the passion and commitment of those who created the program. she gave us permission to give this quote. i will close with some of the results. this is the v.a. study that came out in 2014. the highest rated program in the v.a., 12% lower costs. a study of our program showed similar mortality, high mortality of both controls and cases, but a 17% reduction. the independence at home year one results, ours had a 20% per capita cost reduction. that was $1,000 per patient month. close to $12,000 per patient year. nine of the 17 programs were paid savings ranging from six to 31% savings. in year one, 25 million was saved in 12 million was returned to the providers. i will close with just what are the challenges going forward. finding the skilled work force is probably the number one goal. it's very doable. the people are out there. you have to have a financial model that will support them. you have to build a lot of practice capacity to support these teams. all the other service partners. then you have to have a health system that will commit to really doing value-based care. unfortunately, med star is building a new team in baltimore based on the independence at home results. both the quality and the cost savings, because they have faith that cms and other payers will row ward this kind of care. finally, how can you all in this room help? i would -- we are working with senate finance house ways and their sugar level doesn't matter that much when they just have a year or two left of life. it has to be within parameters. make sure it's relevant for population. cms have been working hard on independence at home to target the right patients who have persistent high costs, use fair and very rigorous criteria for new practices as we roll this out across the country that will preserve the quality and the impact. use really good fully risk adjusted methods when you do the outcomes of the analysis so it's fair to the government and provider. here is a picture of our team. this is a team of 20 people here in d.c. that do the work. finding the right people is the key to success. thank you. [ applause ] >> i just have to say that i had the privilege of sitting in on a team meeting and shadowing george toller who is your partner in crime. this is the work you kind of hear about. this is team-based approach. it's collaborative. it's using people to do what they do best in different capacities. and if i had someone who was old and sick and impaired in d.c., i would be thrilled to give you a call. >> thank you. >> great. we're going to move now to jim garnham who will give us his own perspective from the university of rochester medical center where they are trying out bundled payments. jim. >> great. thank you. i appreciate the time to be here this morning or this afternoon. i do want to just level set understandings of what bundle payments are. it's a single budget for an episode of care. we have a little bit of a definition around that. it starts with in our case an in-patient admission. what we call the anchor admission. it goes out beyond discharge out to again in our case 90 days. there are options for less time than that. it includes if you think about everything that happens to the patient after they are discharged from the hospital, in-patient, out-patient, physician, nursing home. there was a term used earlier today about patient centricity. and what marilyn said is the patient comes first. if you think about a patient-centered approach to care, i think first and foremost about bundles. if you think about somebody has knee replacement surgery, how have i conceived it, if i need knee replacement, think bundle starts at the episode or the episode starts when i go to my doctor and say, you know what, the injections aren't working, the medication isn't working and it ends when i go back to golfing and now i have a better excuse for how bad i golf. that's the totality for me, the concept of what knee replacement is. that's how patients think about. it's not how we finance it. it's now hot we pay for it. i'm excited to be part of this program because i think it very much is a much more patient centered viewpoint. as you can understand, if we're at risk for that care, then there's a huge incentive for us to reduce unnecessary care and reduce unwarranted variation. that's what we started with. we started with do we have volumes here that would indicate that we -- it's worth doing and do we have variations that would say that there is something that we can do to reduce that variation standardized care and improve care and reduce cost. but while this is a financial arrange mntd ant contracting arrangement and that's why i'm involved, ultimately, first and foremost, this is a clinical practice. it's a clinical program. so we had to go to them. we took the data which is great and we went to the leads of our service lines and said, here is some opportunities. here some potential opportunities for us to improve care, reduce cost and really dip our toe into value-based payment. what would you do differently? what would you do to go after this opportunity? what resources would you need? how much would it cost? how quickly could you get there? what kind of outcomes do you think you could achieve? >> do we have the clinical knowledge to get this done? ultimately, do we have the clinical leadership that can actually get it there? this brought us then down to the major joint replacement as one opportunity. then congestive heart failure as the other. these are very different programs. so this is just a little bit of the data that we started with. this is our baseline data, some of it. each vertical line is an episode. the colors indicate where the dollars are being spent. it doesn't take a rocket scientist to figure out, green is probably where we need to focus. for major joint replacement, it's skilled nursing facility-based rehab. we started out at 74% of our patients were going home with skilled nursing -- to a skilled nurse facility. we can probably do better than that. we can get it down to 25% within a year. congestive heart failure, different story. there is some skilled nursing facility. but i look at that and i go, what is red? how can we eliminate it? red is readmission. the whole thing about congestive heart failure is keeping people from coming back. if any of you have anybody in your life that has congestive heart failure, you know the revolving door. so we have nailed down what the objectives are. now we have to have a plan to get there. so we start obviously with the inpatient side. the hospital is the one at risk. we have the right folks in the room. this is not just about improving care in the hospital and handing it over to the post-acute side. we brought the post-acute folks into the facility and said, work with us. help us understand these patients. help us figure out not only what we do here but also what you do on the post-acute side. let's coordinate and let's have a unified plan of care across this continuum. then we need -- once we figure out that, we need a way to keep track of those folks. we have a couple of resources. one is a dashboard, which is just a way to -- a place to put people. it's a software package. we can keep track of people. the real key is the care naf gator. one person who has specific focus and responsibility to watch these folks across the continuum of care. not just in, okay, here we are done at the hospital, here you go. it's continuing that process all the way through the end so they are there -- a single point of contact for patients and for providers. then the other major resource we applied was enhanced home care. for joint replacement, clearly it was getting rehab done in the home with home care and not in a sniff. for congestive heart failure, different approach. it's all about applying those home care resources in a rapid environment so that instead of picking up the phone and calling for an ambulance and going to the ed and back up to the hospital, it's you call the care -- the nurse navigator or the nurse visiting nurse service and say, come out and do an ceasement. they can bring telemedicine resources so we can do a consult with cardiology. on site and even administer iv medications if that's what's necessary to keep folks from coming back into the hospital. so results. we all care about results, right? this is major joint replacement. green line is rehab. you see there were 74% at baseline. we set a target for 25%. we have already blown through that. but that's not enough. we want to make sure we're not doing that and then people are coming back into the e.d. or back into the hospital because instead of being in a snf where they are getting good care, they are home and not getting the care they need. our e.d. visit rate actually went down. not only did it not go up, it went down. we are very encouraged by that. and we did then the cost curve. we did achieve what we were looking for. we think we can do better. congestive heart failure, completely different population. we have not yet really solved the readmission problem but there's one shining star in this. remember, we said we had this clinical pathway and part of that was home care, enhanced home care services to this population. so if we look at just the population that went home, didn't go to a snf, the people that went home with no home care which means they were offered and refused it, they came back at least 40% of the time, 47% of the time, they came back at least once. if they went home with a home care agency that was not one of our partners, they came back 43% of the time. if they went home with our partner home care agency that was committed to applying those rapid resources and doing telemedicine and iv lasix administration, the medication we use to control fluid retention, 17% of the time they came back. so there's a glimmer of hope here and i think if we just keep focusing on that model i think we will do better. so i just want to, in the 30 seconds i have left, i want to just say there's one piece of this that i'm really excited about, and sort of the spillover effects and the lessons learned, and that is you would expect the clinical leaders would all be about hey, let's apply these resources, great resources to more than just the medicare bundled payment folks. so we have had that. we expect that. what i didn't expect is i have just as much attention from the administration of the hospital saying how can we leverage this to other patients, we have a unique opportunity here to really improve the quality of care that we're delivering, reduce the costs that we're delivering. how can we figure out a way to afford this to broaden it out to other populations. that's a really exciting place for a policy wonk like me to be, because usually you're trying to drag along the culture and instead, i'm seeing the culture change before our eyes. so i will end with that. and we will take questions. >> great. thank you for that very, very specific information about these on the ground programs. it's incredibly helpful. we are now open for questions. i invite folks in the room to come up to the microphone. i invite anybody who would prefer to write a question on the green card and our staff will be around to pick up your questions and bring them to us. if you are at home watching this live on c-span, please tweet a question. anybody in the room can also tweet a question. again, the hash tag is medicare demos. while we are getting folks set, i will turn it over to trisha to kick us off. >> i think i have -- this is a question for patrick. we did some work a few years ago that looked at people who live in nursing homes, so people on medicare who have very high rates of emergency room use, they go in and out of the hospital, they are high medicare spenders even though we don't think of medicare as the place for medicare spending for nursing home residents. i think there may be two demonstrations, a new one and an older one. could you tell us a little bit about how they are moving and what the early evidence might be? >> there are two. they are both managed by innovation center and the office that was alluded to focused on beneficiaries in medicare and medicaid. the first was around evidence-based practices and implementing those to decrease admissions and readmissions. we did see early evidence of a decrease of admissions and readmissions and higher quality, but early in that program. then we overlaid a financial incentive on top of that model to really reward financially as well if we were able to prevent admissions and readmissions. this is a population that we care about deeply and two models that have not been certified for expansion yet. but the early results are promising. >> great. let's move to the microphones. >> i'm dr. caroline poplin. i have a specific question for dr. de jonge and a more general question. the specific question for dr. de jonge is home health visits. my understanding is that congress has been cutting the amount of money for home health because they think there's a lot of fraud in the program. the fraud that i have seen, because i'm also an attorney, is for-profit home health care provided to people who don't need it while avoiding the people who do need it because it's expensive. my question for the panel is along the lines of marilyn moon, is value for whom? i know value is supposed to be quality over cost, but are the patients involved in the quality measures, and i don't mean patient satisfaction surveys, because for a healthy patient, that's parking, and ability to schedule, and to call the doctor at night. and for a sick person, it's time with the doctor, to ask all the questions and get the explanations and get some empathy. >> yes. there are two questions there. one is just about home health care. the medical house call home based primary care model taps into skilled home health care as needed. we have found many very good ethical high integrity home health care agencies we work with. we use them when we need them for episodes of care, but they are part of the team in the ih model. then in terms of -- could you restate your second question? >> the second question has to do with value. when we talk about substituting value for volume, i guess you're talking about quality over cost, but value to whom? >> from my perspective, independents at home looks at this as well, value to the patient and family in terms of their goals, their outcomes. one of the six metrics that's directly linked to savings is whether the patient and family's goals and preferences for ends of life care are documented, whether they receive a house call within 48 hours of going home. so it's value for the patient and family first, and then value for the payor in terms of being able to afford the care. i think it has to be both. >> i would like to hear dr. conway address it or some of these other people who are involved in the program setting them up, setting the quality measures, whether patients are involved in the quality measures. frankly, i don't care how many mammograms my doctor has ordered. >> i think you're making a good point. i think one of the things that makes most sense to me when you look at these models is to think about whether or not there's actually both flexibility and coordination that goes on, because then you are talking to the patient and you are getting involved in what the patient wants, and it seems to me that in terms of achieving those goals, the kinds of things that we were hearing about both in terms of the bundled payment and the independence at home have a better opportunity to do that than ones that are really focused on, are more technically focused and don't involve the patients as much. >> we do have patients on the various quality measure development teams and committees that review quality measures for implementation in various programs. it is critical. >> so let's move to the other side, if you could please identify yourself. >> i'm joanne lamb from the institute center for elder care and advanced illness. i'm delighted that we are on this journey. i feel like we are sort of lewis and clark in their first winter, knowing where they're headed, sort of, but having no idea how far away it is and what they will encounter. but i think that really continuing to work on what it is we're trying to get to is an important part of the endeavor, because some of what we are now doing may make it harder to get to where we hope to go, and in that light, let me invite folks to weigh in some on where it is we're going. we talk about total costs of care as if that's an obvious idea. we are only talking about total costs of care in medicare. the big issue is long-term services and supports and especially family care givers. when we cut out all the snf days and we're terribly proud of it and sharing our profits with the providers, we forget that means families have to take people home much sicker still with their wound clips in, still unable to do a two-person transfer and someone has to cope with that. someone loses work. the care giver, the average woman family care giver loses a quarter million dollars toward her own retirement by taking care of her mother. that's big. but we don't account for that. the big issue is not -- it's a big enough issue just what we're going to do within medicare, but medicare has this huge kind of semi-permeable barrier with long term services and supports and it's even bigger especially if you start counting family caregiving. if we start counting quality measures in that arena we get into things like people not wanting to be bankrupt, not wanting to lose the ranch, not wanting to be a burden on their kids or grandkids. it seems that the vision like lewis and clark trying to imagine the pacific has to include some real end point that isn't just paying providers for doing what they ought to have been doing 20 years ago. eric and george started their effort 20 years ago. we knew then what we needed to do. it seems that we really have to start kind of planning these modifications in light of where we hope to get to and that it seems might require thinking in terms of small localities, at least for these very sick people. it doesn't matter -- >> are you going to a question? >> i want them to weigh in on whether this seems to be where we're going. one of the directions for movement would be to really take account of the seriously disabled, seriously frail elders in a geographic community and build the capacity more broadly there. much of what we are now doing makes that harder to do, because we are building, financing and quality measure lines that do not support that endeavor. >> let's see if we can get a reaction from the panel here. anybody? >> i can take a little bit of that. you bring up a really good point and i think it deserves a lot more than i have the time to address today. let me just give you just a small sliver of what we're doing. so we don't simply turn people over to their home and say here you go, good luck to you. it actually starts well before the surgery, when we are talking about joint replacement. we actually go out to the home, meet with that person, meet with their care giver and plan their discharge with them and their care giver jointly so it is not just our decision to say you're going to go home, it's a joint decision with the patient and their care giver and the provider. so you are absolutely right, we can't just kick people home and expect that the family's going to pick up the slack. >> great. let's move to the other mike. did you have a comment, patrick? >> you obviously talk a lot so i won't give a long answer. i think we are trying through accountable health communities through some of our medicare transformation work including on long-term services and supports and some of our state innovation work to start to address more of these issues and the holistic care paradigm including out of the provider system and really testing models at the community level to improve health, and health outcomes. i think it's a fair point that we have more learning to do in this arena about how to do that the best way possible. >> great. so thank you. let's move to this microphone. >> thank you. my name is amy gibson. i'm with the patient center primary care collaborative. i want to build on some of the comments marilyn, you were making about how we get buy-in and why buy-in among patients is critically important. one of the things we have come to realize is you really need to have them involved as partners in the design of the program from the very beginning. we just heard from a panel of patients in a conference in chicago, from a patient who reminded us that quality is assumed by patients. so when they are going to get advice on where to go to get their best care, they are not necessarily looking for a four or five star rating that shows them that the quality is good, but rather, as you address, that they are going to their friends to find out did your doctor really listen to you, what was your experience in care. i think if we have the conversation with patients around improving experience of care, and they also absolutely understand value of care. dr. conway, i certainly want to first and foremost applaud cms for all that you have done to demonstrate how important those collaborations are from the very beginning. our organization is funded as an alignment network specifically to facilitate these collaborations and meaningful partners with patients and families in clinical redesign. dr. conway, i just want to kind of have you talk about that and some of your learnings and how cms is starting to evolve those relationships and even through the expansion of programs that are successful and new programs that you're developing, what are you doing to better assure that there is that collaboration meaningful partnership with patients from the very beginning? >> yes. thank you for the question. it's a critically important issue. a few things we're trying to do. one which was talked about earlier, the sort of quality measures and what's the quality focus. we think patients and care givers are the most important voice in that equation. we are doing this now and i appreciate the positive comments. i think we need to continue to do it better. how do you engage patients and families really in the design as you said. and the life cycle of the model. and i think this is something we have met with a number of groups, thinking through this, and how to do it more systematically so stay tuned for even more. i think we agree with the concept that you want patients, people, consumers, families and care givers to use all terms to be as inclusive as possible to help design these models, to be co-creators both at the start through the evolution of the model as we try to improve models and in aspects of evaluation such as the quality measures involved. >> thank you. >> so let's move to a question from one of our green cards. we actually have a few questions on the issue of how well does all of this work in rural areas. several of the demonstrations we have heard about are sort of well suited for areas where there's a concentration of people and providers, i think there's a story in the paper this morning about some of the challenges that people in rural areas face, especially seniors. i think a quarter of all people in medicare are living in rural areas. this is really for anybody in the panel. we have talked about scaling up things that work. do they work in rural areas? >> this is eric de jonge. i think independence at home can work in any area of the country, rural, suburban and urban. the challenge is how do you staff it. in arizona and new mexico, there's an ih life kind of home based primary care program that uses more televideo. these are slightly different staffings. the doctors are sometimes more consultants but you can achieve the same goals of keeping people at home, using mobile technology with a slightly different kind of staffing mix. but i think this can be done in any geography. >> just building on that briefly, this is an issue we focus on significantly. i think the primary care models can be done in rural areas. we did advanced payment, other methods in our program which had the vast majority in the last round of participants were small practices or rural practices to help with the transformation work. we also are engaging with a number of states that are thinking about population based payments for rural areas and what that might look like. more work to be done but a number of these models with work successfully in rural areas and how can that be done. >> my name is jenny boyer with health net federal services. we are the contractor that manages tricare in the northeast. >> might pull the mike a little bit closer. >> sure. my question, especially to those of you who are involved in making policy, all the pilots are great when it's well known and high quality facility for a small area, but how do you scale that for the whole country and what happens when the quality inevitably deteriorates? >> that might be for me again. so a few thoughts. one, the majority of our pilots are voluntary, either community, state or provider pilots. you are seeing a number now like the joint replacement which are testing in a geographic area including all providers in a geographic area. the sequence there as we saw early positive results in the joint replacement model from the bbci, the bundles model that was talked about. now we are testing a geographic area to learn what you just described. will the results be the same in a diversity of providers. we do have monitoring, we are trying to minimize unintended negative consequences and trying to eliminate them if possible. we have monitoring, we have the ability to pull people out of models. we have other tools we use when we have major issues. but i think you need an array of testing strategies. you picked up a lot of the early doctors and now we are moving to the big middle and shifting the curve as was alluded to. it's how do we now learn in this sort of big middle of transformation and what works with the big middle, if you will. how does context, sorry to answer long, i try to be brief. it's a good question, though. context of the providers really matter, et cetera. so we are trying to structure this now in a sort of step-wise progression that picks up an increasing number of states, communities and providers across the country, including ones that maybe historically weren't high performers but want to be high performers in a population of construct and lastly, sorry, supporting people. we are making major investments through transforming clinical practice which was alluded to and other initiatives to support various providers states and communities to improve. >> marilyn, could i just add that i think that not only do you see in the beginning that high performers but you often see the highly motivated and ready to change folks. and it's the not so ready to change people that you worry about then bringing these two. so i'm glad to see dr. conway talking about the importance of them providing additional resources and providing education and information to people, because they -- the leaders already are motivated to change in many cases and it's the folks who are just not sure that's what they want to do or are skeptical that you need to bring along. i think that is a really important aspect of the next stage of all of this. >> thank you very much. >> great. we have another question at the mike. >> hi. i'm carl poser, co-chair of the long term care discussion group. i really enjoyed the presentation about the independence at home program and the savings to medicare and the quality of the care. but i thought of this question before the other two questions. but it's sort of a follow-up. what do we really know about the incidence of long term care medicaid costs and the burden of unpaid care giving around and if you don't have specific studies, what's your sense? does it also save in assisted living, nursing home and home care, long term care services or doesn't it? and what about the needs, you know, the pull on the unpaid care giver? >> sure. thank you. so in our practice here in d.c., we have a less than 5% incidence of nursing home placement per year, so about 95% plus of our patients stay at home long term. that's much lower than kind of the benchmark around the country for this population. we haven't done the medicaid cost analysis. there's actually a number of both at penn and i know within cms some interest in doing that. our experience is if you have social workers on the team as we do and you have the true inter-disciplinary approach and get the care for the care givers and the patient in place, the kind of amount of nursing home placement and then therefore medicaid costs significantly less. >> i'm afraid this one might be for dr. conway, too. maybe anybody else want to join in, that would be terrific. everyone including presidential candidates is talking lately about the problem of rising drug costs. how will these demos address the problem and are there any particular demos that directly address this issue? i think i know from where you were speaking this morning that you have a specific demonstration to talk about. >> yes. so a number of the models before i talk about the specific one do include drug costs, typically b costs, but next generation even includes the possibility of organizations bringing in d costs. our own care model which we had robust interest in, we look forward to announcing the participants, also includes both a and b costs so includes drugs. we do have a part b model which i spoke this morning about that directly focuses on paying for value and better patient outcomes in part b. i want to say clearly it does not limit access. we do not believe the proposal limits access for any patient to get any drug they need and any physician to describe any drug they think is warranted. if there are examples that people can provide around limiting access we would want to know about those because access and focusing on better patient outcomes is a core principle for us. it's a proposal we are seeking comment on that we could be directly aligned with paying for value in the drug arena. >> you have another question at the mike? >> this is christine grossman with the alliance for specialty medicine. i actually had a question actually for jim. i used to work at cms actually up until quite recently. i had a question on your bundled payments portion. so you talk about the episode of care lasting until 90 days post services. i heard you have several docs both now and in my previous position in the past at cms having issues in terms of following up with patients and you know, getting information past 90 days. i wanted to see if you all account for that and you know, what you do in terms of if a patient doesn't follow up and how that computes into bundled care. >> patient followup is a huge issue for us, particularly for the congestive heart failure. i will tell you a little bit of a story. this is only tongue in cheek. one of the medical directors of the congestive heart failure program said that if he could find a way to combine the oral lasix medication which is the drug we use for fluid retention with crack, then we could get our patients to be compliant. he was only half-kidding. so when you talk about patient followup, we have care navigators that are constantly calling and visiting folks to try and get them to come into those follow-ups which is one of the reasons why we have initiated telehealth services through the visiting nurse service so if they can't get back to the clinic for their followup appointment, we will go to them so they can have that visit wherever they happen to be. but patient followup is one of the hardest things to do in this population. >> thanks. >> okay. thank you. so to follow on that, let's talk about additional implications for patient involvement. so there are some pros and cons associated with passive enrollment in these models of care. what are the implications of more or less patient beneficiary involvement? >> i can comment a little bit more as an analyst looking a bit like you said at the pros and cons. i'd say -- and while some models are being introduced in the future that allow more patient engagement, some of the ones we have results about now have more the passive attributes. i think some of the thoughts behind that are that in the one hand, it's not very disruptive to the patients. this is going behind the scenes through claims-based analysis, and then it in fact places greater -- a greater role for the providers to really engage the patients and work on the care. and also it eliminates some of the selection issues that i think marilyn sort of brought up, where although this is more i think some of the thoughts behind that are that in the one hand, it's not very disruptive to the patients. this is going behind the scenes through claims-based analysis, and then it in fact places greater -- a greater role for the providers to really engage the patients and work on the care. and also it eliminates some of the selection issues that i think marilyn sort of brought up, where although this is more the patient selection, where patients, whether they be recruited or not recruited, so some of the passive enrollment from an analyst's perspective has some merit. but on the other hand, you're losing by this passive attribution, you're losing patients volunteering to be part of this model and then being more proactive in listening to the care decisions and making choices about which providers might in fact be higher quality, lower cost. so i think there is a push and pull, and i imagine that the future models that are coming are going to be assessing both that push and pull about selection issues versus patient engagement and patient involvement. >> and for some, it could be both. that there's both passive populations plus active choice populations on top and so we do want to learn how to do this best and what's the sort of deepest level of patient engagement necessary and i think just to build on the answer which i agree with, on some models it may be both. >> so i want to note, we have 15 minutes or so to go through -- to get through more questions, but i want to point out that in your packets you have a blue evaluation sheet and we would be very grateful if you would take a moment to fill it out. we have actually made it a little bit shorter so it's easier to fill out, so we would be grateful if you did that. this is not an invitation to leave. so i would actually like to ask patrick and the others up on the dais to look into the crystal ball into the future, into the next year, into the next two years, to give us an idea of what's coming next, whether it be expansion of some of the programs we are already seeing in demonstration projects, whether we are expecting to see some new kinds of programs that are bubbling up that aren't necessarily part of the demos but they are starting to come about in the private sector, what will be the focus? what do you all see coming down the road if we look ahead? >> i can start on this. so great question. first, at a high level, i actually see the level of transformation accelerating and my prediction is that may continue in a positive direction. i think i'm seeing a cultural shift. three or four years ago i talked to a big group of ceos about this and i could tell yeah, yeah, that may happen some day but not that worried about it. including a very tangible example where the person said i will never be in one of your models and now are in a bunch of our models. it's because you have seen a cultural shift that people know this is where we're going, it's the path we're on, we need to learn how to get there. i think the progress will continue. regardless, delivery system reform i think is truly bipartisan. then on the details, three things. you will see increasing -- we announced the certification of the diabetes prevention program which we haven't talked about today. a few weeks ago, i think you will see increasingly results that meet the bar for expansion and therefore expanding the program. you will also see us take learnings from programs even if it's not formal expansion and propose them into various programs. two, i think you will see continued models that fill gaps like the conference and primary care plus model today. we are working on direct consumer oriented models that are complicated and hard to get right but we worked on health plan innovation which we haven't talked about much today. the drug space, you have part b model that's a proposal. you will see gap filling. then three, i think this private sector public partnership aspect you will see accelerate. increasingly when i interact with private payers in states and medicaid programs there's agreement on this is where we need to go. there is actually agreement on a lot of the high level payment models. i think you will see a shift across the public and private sector which i have been on the provider side and had to deal with, makes it much easier to succeed if you are getting a common signal across your payers from your state, et cetera, about moving to this alternative payment world. >> i would like to talk about how this will affect things. i think the argument for increasing impetus for change comes from the demographics of the baby boom population turning 65. much more accustomed to questioning authority, much more accustomed to being skeptical about being told something by a physician, for example, and with all of the attention and publicity around change, i thin publicity around the change, i think that recognizing that change is not only going to be coming but that they -- that people want to have a roll in it and have to be active. on the passive side or the more troubling side, we will have an increase in the population of diverse people on medicare program than we do now as increasingly the the number of latinos and african americans increases the share on population and that means that you have a bit more of a challenge in reaching out to those people that have a different cultural background on the hispanic side where we know from a lot of research that people behave differently and respond differently and interact with the health care providers differently. that's going to mean unless we reach out and try to provide good outreach and education there will be some problems there. it can be on the one hand and other hand, i guess. there will be some work that needs to be done. >> i have one more change that i feel that i see has come up here and on the panel and that's you how the workforce. i see that changing a bit where we have the navigator with the bullet wounding that's mentioning in rochester, and we have the community health workers involved in hospitals in the paper today. i think in the rural areas that came up as a question, there's different models that may have the ability to coordinate care across the set issintings and ty go hand in hand if they find ways to marry those in the workforce. that needs to be cultured. there's other systems to develop that. >> i have a question which is we're talking about changes in traditional medicare and really learning from different models in order to improve the way that care is provided. i am wondering how all of this relates to what is going on in the medicare world and whether or not some of the lessons learned are being applied to the traditional medicare and the things that are working in traditional medicare and being injected into the medicare space and how would a beneficiary know? >> yeah, so is others can jump in and we're having this by learning and approaches and then describing briefly further. so there's an example of the model and then the value base design that we launched in the medicare advantage and seen that in the private market and that's bringing the market and testing them in the medicare market. i interact with the medicare advantage and through the various clinical quality and innovation leader. we're learning from them on the work that they're doing as well. i think that like wise there's examples and aco's and bundles and primary care where we're sharing directly and doing with other pay ers and encouraging them. we can encourage but not require which is appropriate. encouraging the various medicare plans to adopt or consider adopting the various models, and we're seeing that happen. you're going to see the way that medicare advantage plans pay providers and increasingly converge over time. >> this is a quick follow up and that's at home and it's the high cost of people that are living in the community. is that something that is part of the care system that medicare advantage plans are providing as far as you know working with the medicare plans to be sure that the best practicing are being replicated for the the beneficiaries no matter which delivery system that they choose. >> can i take that up. programs are having contracts with medicare and that cover s the cost of the program and gets them into the black and now doing that care as we speak. >> we have the medicare plans and commercial plans. >> mine transform the advance care, and these models are great hopefully they will continue to be successful, but how will we coordinate these models and if they're an elder that needs a hip replacement, you're can an aco and then at home and a bundle payment? i know that they need to be the from an evaluation standpoint, but how is it going to come together? >> can i just say from the doctor perspective on the ground that the patient population has to drive the financial models and the payment models, so you have a will tlot of models and s program, we take care of the patient from day one until the last day of life, and all of that care is an in dependence at home. we're not in an aco because right now they're exclusive. we do not participate in the pu bundles, so i h is a stand alh program. that's how it is now. >> we have the alliance and we will continue to work on those you issues. >> what we will find is the financial mechanisms that are working and become how they're paid for and organized. we're going to have to work through the the issues. we did this a few years ago and then bundled together. >> we think that there's a hope for consumers and the whole idea and that's why it's important. and there's the type of lung term and so in event it's going to be good for the medicare to do over time and to provide some kind of services and they're going to potentially structure and the long term services. it's the program that people would enroll in and then that's for which it's going to manage and the whole idea of managing it and to the family members and then the area that's that and maybe even a model on to itself. >> i think that we're wrapping up because while we do have more questions, i don't think that we can get to our questions. i think that it's a plus for the. you can find that on the webs e website. you can scream line the evaluation form. thank you very much. we will begin shortly here on c-span 3.

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