Beruflich Dokumente
Kultur Dokumente
PUBLIC MEETING
COMMISSIONERS PRESENT:
GLENN M. HACKBARTH, JD, Chair
JON B. CHRISTIANSON, PhD, Vice Chair
SCOTT ARMSTRONG, MBA, FACHE
KATHY BUTO, MPA
ALICE COOMBS, MD
FRANCIS JAY CROSSON, MD
WILLIS D. GRADISON, MBA
WILLIAM J. HALL, MD
JACK HOADLEY, PhD
HERB B. KUHN
MARY NAYLOR, PhD, RN, FAAN
DAVID NERENZ, PhD
RITA REDBERG, MD, MSc, FACC
CRAIG SAMITT, MD, MBA
WARNER THOMAS, MBA
CORI UCCELLO, FSA, MAAA, MPP
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AGENDA
PAGE
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P R O C E E D I N G S
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[9:24 a.m.]
MR. HACKBARTH:
recommendations.
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perspectives.
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beneficiaries first.
I think that's a
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And I can't
these issues.
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deal with.
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last 15 years.
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payment systems.
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efficiency providers.
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Providers may not like that, but I take pride in our role
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the work has been strong, and some difficult changes have
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been made:
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providers.
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payment.
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education.
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Medicare beneficiaries.
Long ago, in fact, one of the very first
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or enrolled in an MA plan.
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know I am.
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after month after month and year after year after year.
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welcome and I'm grateful for the interest that you've shown
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[Standing ovation.]
MR. HACKBARTH:
Can we go on now?
[Laughter.]
DR. MILLER:
MR. HACKBARTH:
Okay.
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Thank you.
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[Laughter.]
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MR. HACKBARTH:
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Zach?
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MR. GAUMER:
But I do count.
Okay.
Good morning.
Today we'll
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repeatedly.
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observation status.
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administered drugs.
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status.
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In its work
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Second,
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directive to auditors.
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We
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implementation.
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address.
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In addition, some
services.
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concerns.
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The lengthening
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It will also
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denied.
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stays.
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more efficient.
efficient.
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system.
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coverage.
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This
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Medicare
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status in observation.
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"The Congress
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services.
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We expect that
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home.
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The extent
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hospital.
inducements.
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payment system."
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charges.
from beneficiaries.
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administered drugs.
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today.
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MR. HACKBARTH:
Okay.
Stephanie.
So, we'll have two rounds, our usual clarifying
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vote.
So, let's start with clarifying questions.
there any clarifying questions from Commissioners?
DR. HOADLEY:
Are
Jack.
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MR. GAUMER:
That's correct.
There is some, I
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should be defined.
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DR. HOADLEY:
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define exactly what the time period should be and we're not
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MR. GAUMER:
That's right.
So, the
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DR. HOADLEY:
MR. HACKBARTH:
MR. GRADISON:
Great.
Thank you.
Clarifying questions.
Thank you.
Bill.
In the mailing
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MR. GAUMER:
Yes.
Let me go back.
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court.
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December.
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signed.
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MR. GRADISON:
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MR. GAUMER:
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MS. BUTO:
Thank you.
Okay.
On the
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MR. GAUMER:
Did we look
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MS. BUTO:
Mm-hmm.
MR. GAUMER:
MS. BUTO:
MR. GAUMER:
MS. BUTO:
Okay.
-- and that's where we --
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MS. CAMERON:
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of surgery to be included.
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MS. BUTO:
Okay.
MS. CAMERON:
MS. BUTO:
MS. CAMERON:
DR. SAMITT:
A total of 100.
Okay.
Great.
Thank you.
chapter.
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Stephanie.
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potentially?
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MS. CAMERON:
I was
So, if
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professionals.
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DR. SAMITT:
MR. KUHN:
Thank you.
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MR. GAUMER:
That
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MR. KUHN:
Yes.
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[Laughter.]
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MR. GAUMER:
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MR. KUHN:
That's correct.
Yes.
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MR. GAUMER:
Okay.
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MR. HACKBARTH:
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[No response.]
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MR. HACKBARTH:
But, we
Okay.
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two.
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recommendations.
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one by one.
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And, as I say,
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MS. UCCELLO:
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thank you.
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MR. KUHN:
So, I
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package of recommendations.
There's a lot of
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1965, and who would think that we're here in 2015 still
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like, to a degree.
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we have been back and forth on this issue so much over many
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DR. CHRISTIANSON:
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DR. CROSSON:
recommendations.
Thank you.
I thank the
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It is, in
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DR. NAYLOR:
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So,
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DR. HALL:
confusing literature.
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administrative issues.
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patients.
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illnesses.
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true statement.
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now.
MR. GRADISON:
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DR. NERENZ:
Yeah.
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problem.
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And, the things that we've talked about here, I think, are
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called stays.
And, I think we
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dichotomy.
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going forward.
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MS. BUTO:
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So I want to
I want
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length of stay.
those stays are medically necessary, and once you get into
trying to sort of slice and dice and only look at the not
process.
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rule.
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penalty.
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unnecessary.
DR. COOMBS:
discussion on appeals.
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I just want to
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they talked about was the whole notion of the probe and
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When they
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disappointing answers.
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Thank you.
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DR. HOADLEY:
Yeah.
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every one of them exactly the way they came out, but we're
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MR. HACKBARTH:
Oh, Warner.
MR. THOMAS:
Any others?
Number
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I just want to
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RACs because depending upon the rates you look at, between
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I know
I would just
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comment on.
I know that
I would just
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approach.
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be a challenge.
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If we're
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well.
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On the
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comment.
point.
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I just
Thank you.
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easily accessible?
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MR. HACKBARTH:
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[No response.]
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MR. HACKBARTH:
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Commission that we all long for the day where we're focused
less on how we manage the siloes and the problems that the
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[Show of hands.]
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Draft
All in favor of
Opposed?
Abstentions?
Okay.
No. 2.
All in favor of
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[Show of hands.]
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MR. HACKBARTH:
Opposed?
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[No response.]
MR. HACKBARTH:
[No response.]
MR. HACKBARTH:
[Show of hands.]
MR. HACKBARTH:
[No response.]
MR. HACKBARTH:
[No response.]
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[Laughter.]
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[Show of hands.]
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[No response.]
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[No response.]
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Abstentions?
Okay.
No. 3.
All in favor of 3?
Opposed?
Abstentions?
Four?
Opposed?
Abstentions?
And No. 5.
5?
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[Show of hands.]
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[No response.]
Opposed?
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MR. HACKBARTH:
[No response.]
DR. SAMITT:
MR. HACKBARTH:
[Laughter.]
DR. SAMITT:
MR. HACKBARTH:
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Okay.
Abstentions?
It does.
It does.
Or just 17?
I have a calculator set up to do
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[Pause.]
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MS. SUZUKI:
Okay.
Polypharmacy is up next.
Good morning.
Shinobu,
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We went
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Congress.
We plan
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We'll
The patterns we
Here's a
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clinically appropriate.
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Compared
About
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2012.
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Sixty-five percent
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classes.
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In 2012,
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unintentional overdose.
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health benefits.
use of opioids.
DR. SOKOLOVSKY:
drugs.
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concurrently.
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safely.
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medicines.
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medical services.
of work.
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spending.
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And the
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hospitalizations.
Outcome measures
therapy.
some drugs in the morning, some before bed, some with food,
some without.
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hospital to home.
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physician's instructions.
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others stopped.
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They may also find the total cost of the drugs too
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sleeping pills.
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death.
It is a statistically
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One of them
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replaces one drug with another but the patient does not
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risk of bleeding.
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An
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simplifying the drug regimen, for example, how and when the
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Secondly,
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they should take them, and why it's important to only take
them as directed.
issues.
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MS. SUZUKI:
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around lock-ins.
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in Part D.
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with prescribers.
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in policy.
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of opioids.
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edits.
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These
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challenge.
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By dispensing
It may also
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Integrity.
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concerns.
polypharmacy.
And, finally,
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MR. HACKBARTH:
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MR. THOMAS:
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total?
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MS. SUZUKI:
There
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than others.
side to see what that looks like, but the top 5 percent are
are.
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MR. THOMAS:
65 and disabled.
Is that correct?
MS. SUZUKI:
MR. THOMAS:
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MR. HACKBARTH:
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MS. BUTO:
I think we're
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question.
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D plans, right?
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collected back?
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And I think it
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DR. SOKOLOVSKY:
that.
still subjective.
DR. NERENZ:
The term
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thing.
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DR. SOKOLOVSKY:
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question.
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of a thing.
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DR. NERENZ:
MS. SUZUKI:
Oh, okay.
DR. NERENZ:
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MS. SUZUKI:
So
I
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DR. NERENZ:
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MS. SUZUKI:
Okay.
DR. MILLER:
you were very clear to take that off the table for them.
point.
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line.
tool to think about how you manage drug use, should we look
that context?
Next sentence.
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DR. SOKOLOVSKY:
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[Laughter.]
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DR. SOKOLOVSKY:
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DR. NERENZ:
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DR. SOKOLOVSKY:
Nicely done.
If you think about the different
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taking it.
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same time.
additive effects.
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They're taking a
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DR. NERENZ:
That's okay.
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MR. GRADISON:
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get much in the way of useful information, but how long has
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MS. SUZUKI:
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MR. GRADISON:
information?
MS. SUZUKI:
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MR. GRADISON:
Okay.
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about this issue, the more I think that we've got to take a
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registries?
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While
MS. SUZUKI:
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Monitoring Program that states run and how some states have
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think run in the right way, you could get some reduction or
MR. GRADISON:
It is
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MS. SUZUKI:
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state program.
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information.
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MR. GRADISON:
No.
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MS. SUZUKI:
I believe so.
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MS. SUZUKI:
Yes.
I think so.
It is usually the
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MR. GRADISON:
All right.
Well, in that
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like that.
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that on the average, each person coming into the SNFs was
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Thank you.
DR. HALL:
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DR. MILLER:
I'm just
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right now.
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DR. HALL:
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It is not a surprise
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MR. HACKBARTH:
Okay.
It doesn't make
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MR. KUHN:
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am just curious about the first dot point where you talk
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having.
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I just wanted to
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MS. SUZUKI:
Having said
topic.
MR. KUHN:
As you say,
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DR. HOADLEY:
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things.
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plan side.
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When you
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if you risk-adjust?
MS. SUZUKI:
DR. HOADLEY:
extreme case, you could say that their opioid use is only
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MS. SUZUKI:
We
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DR. HOADLEY:
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at the top, the high users, you were looking at high users
defined by dollars?
MS. SUZUKI:
DR. HOADLEY:
Mm-hmm.
Did you also take a look at high
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about the high-cost ones that would say the high-cost users
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high-volume users?
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MR. HACKBARTH:
Round 2 comments.
Why don't we
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just come back the other way and start with Warner and then
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MR. THOMAS:
Just a comment.
I mean, I think,
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DR. HOADLEY:
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say briefly.
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program, and I know, Joan, you have talked about this over
the years.
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Second observation.
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It does seem
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We want some
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maybe the easier one to say if somebody has got the nth new
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patients."
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And we know
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MR. HACKBARTH:
with in principle.
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barriers there.
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Part D into ACOs and have that part of the medical bundle
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MR. THOMAS:
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taken.
MR. HACKBARTH:
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MR. THOMAS:
No.
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with ACOs.
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MR. ARMSTRONG:
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associated.
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populations of patients.
In my own system, for example, I know every
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And
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sure we know what systems that are doing this well are
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doing and ask how that might inform or begin to, as Warner
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DR. REDBERG:
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MEMBERS:
Indiana.
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DR. REDBERG:
And there's
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treat.
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treating depression.
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depression.
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well.
And
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shopping.
been.
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track medications and know what people are getting and what
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DR. COOMBS:
The chapter
was excellent.
A couple of ideas I have.
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intersecting with CPOE and what that means for the rollover
longer necessary.
That's no
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think the provider one day wakes up and says, "I'm going to
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event.
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could be a fall.
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medications.
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I don't
It
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get at.
And so
But I
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that correlates with your crescents from your map and, you
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know, the map that you had, the Southern crescent, we call
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providers.
it.
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MR. KUHN:
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talking about this new benefit, this MTM benefit that was
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going to be available.
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could take all their pill bottles, put them in a brown bag,
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I recall
I mean,
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about this.
benefit?
Is it a Part D benefit?
Is it a Part B
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some of the barriers that we're seeing and why we're having
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DR. SOKOLOVSKY:
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plan.
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doing that.
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pharmacist.
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answer.
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So that's an easy
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this.
the numbers, but when I look through the reports that have
come out, they seem to be more focused on, well, these are
drugs that you need and you're not taking them rather than
these are drugs that you don't need and why are you taking
them.
may find duplicate drugs, but they're not going the other
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for that.
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the reports.
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plan has to reach out to the beneficiary, but how hard they
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participate."
MR. HACKBARTH:
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they really don't need, the plan would want them to use
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fewer drugs.
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DR. SOKOLOVSKY:
Why
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that you all have been talking about this year, that when
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you're taking really a lot of drugs, not too far along, the
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MR. HACKBARTH:
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DR. MILLER:
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DR. HOADLEY:
Okay.
Well -- go ahead.
I was just going to -- a quick
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follow-up.
work for the plan maybe on a telephone line rather than the
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DR. SOKOLOVSKY:
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others didn't.
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is to do it personally.
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for the people who are participating and who are getting
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something.
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DR. HOADLEY:
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DR. SOKOLOVSKY:
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DR. MILLER:
No.
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participate.
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the providers.
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I mean, you
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incentive.
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triggering question.
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MR. KUHN:
And
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40 percent?
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DR. SOKOLOVSKY:
But I think, you know, now you only have to be taking two
drugs to qualify.
people.
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MR. HACKBARTH:
this particular point?
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[Laughter.]
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DR. SAMITT:
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there.
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I have
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are happening.
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satisfaction.
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outliers are.
So
So I very
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the provider.
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these two parts, and I would guess that what you'd find is
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where you see that alignment, you see high use of MTM, that
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create alignment between PDPs and ACOs you need the ACO to
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I would
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Maybe we
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of a quality metric.
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elements of Part D.
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DR. SOKOLOVSKY:
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MR. HACKBARTH:
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point.
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DR. NERENZ:
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MS. BUTO:
On something else.
I'll pass.
Okay.
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else.
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MR. HACKBARTH:
Oh, okay.
Jon.
DR. CHRISTIANSON:
that kind of jump off the page at you that were surprising
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example of polypharmacy.
But, also in the chapter, you had a really quite
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You
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treating patients.
you ferret out and what should you do about fraudulent use
that.
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DR. CROSSON:
Thanks.
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I don't do
So, thank
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written about.
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issue.
That's a separate
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perfectly appropriate.
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we think about this down the line if we might not get more
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issue.
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mechanisms.
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well be.
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I think that's
ago.
providers.
objection.
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MR. HACKBARTH:
Bill.
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DR. NAYLOR:
Okay.
Mary.
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think, for the Medicare program today and well into its
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future.
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terrific chapter.
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root cause.
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so on.
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conditions.
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So, I think
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that by adding more and more medications and now it's a big
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and how it views the almighty pill as the way to solve all
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DR. HALL:
Mary's sentiments.
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renal function.
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special area.
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That's
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medical progress.
there were about six drugs that may or may not have worked.
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This is a disease of
But,
disaster.
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it's not the cost of the drug that's the issue here.
look at this.
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DR. CHRISTIANSON:
It's
That's how I
Okay.
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electronic records.
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should urge that that be done, and we might have some ideas
One would be
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I don't
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know.
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to follow them.
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physicians are.
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It
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loop to doctors.
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MR. HACKBARTH:
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DR. HOADLEY:
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questions.
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electronic prescribing.
Okay.
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prescribing.
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MR. HACKBARTH:
Joan.
Okay.
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[Pause.]
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MR. HACKBARTH:
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Okay.
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So,
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the light comes back on, that signifies the end of your two
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minutes.
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MS. RILEY:
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MR. HACKBARTH:
Two minutes.
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When
I'm sorry.
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MS. RILEY:
Thank you
very much.
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Good afternoon.
Great.
I am
Pew is a nonpartisan
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programs, or PRRs.
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overdose.
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The
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I won't
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you that you will hear we've described in that letter some
in October of 2014.
CMS
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intervention.
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on retrospective interventions.
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emergency rooms.
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the House.
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Is that my light?
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MR. HACKBARTH:
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[Laughter.]
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MS. RILEY:
Okay.
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MR. HACKBARTH:
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MS. COHEN:
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Thank you.
Good afternoon.
My name is Allison
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Colleges.
payment issues.
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For important
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volume.
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Instead,
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targeted.
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MR. HACKBARTH:
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AFTERNOON SESSION
[1:00 p.m.]
MR. HACKBARTH:
Okay.
[Laughter.]
MS. UCCELLO:
MR. KUHN:
MR. HACKBARTH:
10
Do you know
Every day.
We are off.
Rachel and
Shinobu.
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DR. SCHMIDT:
12
[Laughter.]
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DR. SCHMIDT:
Good afternoon.
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Congress.
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Next we'll
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An alternative to Medicare's
We'll also
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all plans each month to lower the cost of premiums for all
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Part D enrollees.
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spend more than the direct subsidy they get from Medicare
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cost.
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cost beneficiaries.
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The direct
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catastrophic threshold.
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benefit.
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Negative amounts (in the green bars) mean the plans paid
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spending.
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prospective payments.
the risk corridors above and beyond the margins that they
spending, and then the plans paid Medicare through the risk
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be happening.
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bids to CMS and the way in which some plan sponsors project
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catastrophic spending.
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ways.
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The
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costs are 5 percent lower than its bid, the risk corridors
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profit above and beyond the margin that was included in its
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bid.
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some.
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at the top.
I won't go
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above that amount, it's taking a lot of the risk for the
That cap is
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percent.
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It doesn't have to be 20
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D subsidies.
This is a very
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the plan under current policy, but only $10 with the lower
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reinsurance rate.
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add the rest of benefit spending in, the plan would now be
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both cases ($100); it's just that the plan would be at risk
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When you
The
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wasn't affected.
payments:
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last time?
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advantageous way.
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reinsuring themselves.
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D plans.
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to offer reinsurance.
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We asked representatives of
Now, this is a
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drug plans.
losses).
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level of spending.
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threshold.
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So Part D plan
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the top when plans may have needed extra help with risk to
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the sponsor had to pay for all benefit spending that was up
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to 2.5 percent higher than what they bid, and they got to
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percent more or less than the bid, then Medicare and the
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intended.
have today.
Given
On the other
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today.
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overpayments to plans.
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Medicare is also
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ratio requirement.
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We
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effect with the 2014 benefit year, and CMS hasn't yet
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sanctions.
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If the
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revenues.
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be checked.
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Part D plans.
alone drug plans that had the most enrollment in 2012, ten
with the LIS and six plans had 75 percent or more with the
LIS.
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risk adjusters.
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We plan to
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We may also
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MR. HACKBARTH:
Okay.
Thank you.
12
So if you
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we may want to know how good the risk adjustment is, that
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is a good idea?
DR. SCHMIDT:
analytical work like Dan Zabinski has done for the Medicare
to be a concern.
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We've
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MR. HACKBARTH:
Clarifying question?
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Let's go
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DR. CROSSON:
Another good chapter.
payments and cost and risk from drugs than, for example,
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anyway.
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not?
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DR. SCHMIDT:
would say.
[Laughter.]
DR. MILLER:
DR. SCHMIDT:
10
Please.
You're right.
I don't know.
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capacity.
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making.
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MS. SUZUKI:
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DR. SCHMIDT:
MS. SUZUKI:
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that, and because this industry was so new and these things
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could just get the whole thing wrong, your whole bid and
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DR. CROSSON:
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Let's say in any given year, any given plan had $100
suspenders.
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over time.
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things.
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[Laughter.]
DR. MILLER:
To his example --
MS. UCCELLO:
[Laughter.]
DR. MILLER:
prizes work.
to go.
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are on point.
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I think
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up.
But then, of course, you would have -- if this is
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But to the
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So she
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DR. MILLER:
MR. HACKBARTH:
Okay.
Jack.
DR. HOADLEY:
we don't have the data on it yet except for what CMS has
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Shinobu's example from the last meeting and the way you
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played out.
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out differently.
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you've got some ability for whichever one was left in place
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MR. HACKBARTH:
Yeah.
So I
Okay.
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MS. BUTO:
I think so.
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to is not only the MLR, but I think CMS Medicare uses other
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even if they did away with the risk corridors, you could do
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DR. SCHMIDT:
MS. BUTO:
MR. ZARABOZO:
Yes.
Okay.
national coverage.
DR. SCHMIDT:
Right.
Yeah.
MR. HACKBARTH:
[No response.]
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MR. HACKBARTH:
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No?
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MR. GRADISON:
Bill.
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please.
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That's a question.
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corridors.
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MR. GRADISON:
DR. NERENZ:
Thank you.
clarifying question.
question again.
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work.
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DR. NERENZ:
Okay.
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DR. MILLER:
Is the difference in up
Is that a restatement
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and the people who think about this should, after 10 years
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Because the
We're not,
The actuaries
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out under the corridors on net, and once again, if you had
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might think you could get your bid in such a way that you
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Maybe we
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Okay.
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[Laughter.]
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this sharp upward bend and then the flatness and the one-
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Right.
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Well, okay.
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DR. SCHMIDT:
But yes.
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DR. NERENZ:
This is a
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Right.
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of program spending.
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Cori is next.
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Right.
So Cori is characterizing
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Here is one
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projecting trend.
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MR. HACKBARTH:
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DR. CROSSON:
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[Laughter.]
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DR. CROSSON:
Clarifying questions?
So
Jay.
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or not?
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No.
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you and Jack saying was that -- maybe just Jack -- the
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MS. UCCELLO:
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DR. CROSSON:
Okay.
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DR. MILLER:
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DR. CROSSON:
Corridor.
I'm sorry.
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more effective.
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and it was high cost, that then the risk corridors would be
DR. MILLER:
I heard Jay saying is you have set this up, and I am pretty
Court.
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[Laughter.]
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What
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flattens out, and then year over year, you just get -- and
MS. UCCELLO:
DR. MILLER:
[Laughter.]
MS. UCCELLO:
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effect.
DR. HOADLEY:
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we would expect.
It's been
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continue to be there.
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growing higher.
MS. BUTO:
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do seem like those two things are very much aligned, given
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MS. UCCELLO:
In
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DR. SCHMIDT:
MS. UCCELLO:
bit more --
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DR. SCHMIDT:
Yeah.
But, I mean, I
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if you get rid of the risk corridors and there is this, you
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presentation.
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--
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MS. UCCELLO:
It's trying to squeeze the admin and the profit, but one
incentives here.
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computing the MLR, not just what the plan is at risk for.
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DR. SCHMIDT:
denominator, yes.
MS. BUTO:
Yeah.
Hmm.
That seems to be a
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mistake.
look at, and I think that's why every time we have this
[Laughter.]
DR. MILLER:
MR. HACKBARTH:
[No response.]
MR. HACKBARTH:
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DR. SCHMIDT:
to that one.
Could
DR. HOADLEY:
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MR. HACKBARTH:
DR. HOADLEY:
The biggest
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go away?
Both?
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DR. SCHMIDT:
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DR. HOADLEY:
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do that.
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no phase-out created.
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MR. HACKBARTH:
round two.
Jack.
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where cost pressures come from and what's the best way to
useful way.
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Where are
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the white box figure, back up, there's still that five
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manage.
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polypharmacy.
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some of those.
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The
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management.
MR. HACKBARTH:
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drugs.
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DR. HOADLEY:
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formulary position.
behind them.
prices.
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MR. HACKBARTH:
Round two.
Cori.
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And, do we
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MS. UCCELLO:
So,
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side along with some of these ideas Jack has about, well,
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MR. ARMSTRONG:
But, I think
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One, I
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[Laughter.]
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It's only
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MedPAC and our staff on those variables that will have the
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DR. REDBERG:
It's
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related to Scott's.
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now, being very seriously at risk for those costs, and not
just Hep C.
DR. COOMBS:
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So, right
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DR. SCHMIDT:
DR. COOMBS:
DR. SCHMIDT:
DR. COOMBS:
DR. SCHMIDT:
DR. COOMBS:
Right.
Correct.
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populations, presumably.
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not just the LIS that's going to drive costs in the future.
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DR. MILLER:
take what you said and think about it and come back.
populations.
Okay.
But,
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completed, but I can try and do that and come back to you.
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Okay.
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they're done.
had that as a benchmark many years ago and still there are
ways around it, and I think that medical loss ratio, the
DR. HOADLEY:
LIS thing.
this plays out, and the kind of data you're talking about
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they intersect.
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plans.
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And, so,
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DR. CHRISTIANSON:
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about.
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think is kind of the naive focus on just the bid prices and
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program is functioning.
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way.
an actuary.
[Laughter.]
DR. CHRISTIANSON:
I wanted to be
actuary.
[Laughter.]
MR. HACKBARTH:
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[Off microphone.]
DR. CHRISTIANSON:
Well, I didn't.
Actually, I
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[Laughter.]
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DR. CHRISTIANSON:
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economist instead.
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heard it before.
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-- so I became a health
DR. SAMITT:
I know you've
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know, I'm not sure why we're so worried about risk bearing
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of the MAPD plans and the PDP plans, already do bear global
independent reinsurance.
So they already do
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DR. CROSSON:
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Cori.
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DR. SAMITT:
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DR. CROSSON:
Or Jack.
Yeah, I know.
I listened to both,
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payments.
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some solutions.
MR. HACKBARTH:
microphone].
MS. BUTO:
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this piece of work to the work that you all have done on
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I could be premature in
Or
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DR. SCHMIDT:
Right.
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can jump in, Mark -- and then next year come back to you
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DR. MILLER:
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say is, you know, this is not atypical for this part of the
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cycle.
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Trying
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Then we'll come back into our regular cycle in the fall and
MR. THOMAS:
insurers?
DR. SCHMIDT:
Do we
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MR. THOMAS:
But
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We can
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of this risk.
today.
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MR. HACKBARTH:
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DR. HOADLEY:
Okay.
Anybody else?
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Craig's comment.
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taken.
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That's
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DR. SCHMIDT:
Is risk adjustment
Is it
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MR. HACKBARTH:
Right.
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DR. SCHMIDT:
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MR. HACKBARTH:
Yeah, right.
is what --
DR. SCHMIDT:
pretty constant over time and is wider than it was for Part
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Right, right.
We'll
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on that.
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in MA.
It seems
I haven't heard
DR. HOADLEY:
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DR. MILLER:
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MR. HACKBARTH:
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They're
microphone].
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I thought the
DR. MILLER:
not sure.
DR. HOADLEY:
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matter of, okay, for every person that gets more sick on
And you do have the shocks to the system with new drugs.
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MS. UCCELLO:
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DR. HOADLEY:
Yea.
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MS. UCCELLO:
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care.
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[Pause.]
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MR. WINTER:
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Okay.
Good afternoon.
I want to begin
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services.
others.
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have identified more than 300 tests and procedures that are
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often overused.
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Under
value services.
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by low-value care.
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benefit.
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First, it
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Medicine.
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Wisely guidelines.
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use.
To
low-back pain.
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as inappropriate.
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Although the
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The broader
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cancer.
The third measure detects inappropriate use of
traumatic headache.
as epilepsy or cancer.
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The broader
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service in 2012.
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Based
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care.
measures.
in your paper.
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Based on the
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ranged from 8.7 under the broader version to 0.4 under the
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narrower version.
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These
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clinical specifications.
versions.
care.
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services.
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claims data.
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inappropriate use.
For
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Before
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care.
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mentioned earlier.
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MR. HACKBARTH:
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Well done.
Herb.
MR. KUHN:
just curious about the first dot point when you put it in
these categories.
categories.
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MR. WINTER:
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would include things like back imaging for low back pain,
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So imaging
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MR. KUHN:
Thank you.
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So we're seeing
MR. WINTER:
I have not
Within
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rapidly.
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forward.
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MR. KUHN:
All right.
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DR. COOMBS:
Thanks.
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16 and page 17, I like the way you display that and
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The
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back pain, total cost for low back pain, and what
of itself.
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spending, like imaging for low back pain, for example, what
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DR. COOMBS:
Yes.
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MR. WINTER:
Okay.
Is
We
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that first measure on the slide, the low back pain measure.
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DR. REDBERG:
It was a really
combination.
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screening.
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2009 and 2012, when you analyzed the task force actually
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beneficial.
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MR. WINTER:
You're correct.
We took the
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after that.
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DR. REDBERG:
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MR. WINTER:
Yeah.
We can talk to them about revisiting
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matter anymore.
DR. REDBERG:
that, but I would just note that means the cost of the test
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look at that where clearly the test score has stated the
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DR. REDBERG:
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MR. HACKBARTH:
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and the fact that this is just 26 services, not the 300
points, you look at this and say, "Boy, these are small
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Okay.
Jack.
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this slide, but in the chapter, you talked about the share
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MR. WINTER:
Right.
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DR. HOADLEY:
1.7 percent.
1.7 percent.
And my follow-up to
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cetera.
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MR. WINTER:
Yeah.
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imagine.
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talks about the total cost associated with the PSA test.
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associated with an MRI scan for low back pain that looks at
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MR. HACKBARTH:
Okay.
So we can look
Clarification questions?
Dave.
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I guess
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literally no.
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different directions.
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MR. WINTER:
The
I think it
Right.
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history.
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value.
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There's higher
it to think as no value.
MR. HACKBARTH:
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[No response.]
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MR. HACKBARTH:
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DR. COOMBS:
Okay.
Clarifying questions?
Okay.
Round two.
Alice.
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people aggressively.
And, so, with the advent of this article, we're
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history and may or may not have symptoms, people will argue
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They came
We have to be cognizant,
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And, it is
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prostate cancer.
So, I think that it takes a while before the
recommendations.
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patients, then you might retract that and say, let me give
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that in mind.
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the ICU, had 27 CTPA grams for rule out pulmonary embolism
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We're not
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DR. NERENZ:
To that
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label everywhere.
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information.
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I would
I would
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the continuum.
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DR. REDBERG:
[Off microphone.]
A very fair
statement.
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Rita.
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DR. REDBERG:
Yeah.
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chair, met last April -- so, I don't vote as the Chair, but
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can't imagine that being told that you might or might not
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of rates.
And, the
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nodules.
getting cancer from the actual CTs was greater than the
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Scott.
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is old news.
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should be.
patients.
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I just
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DR. HOADLEY:
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geographic variations.
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behavior.
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and what are the measures that could allow you to reduce
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MS. BUTO:
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Jack.
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issues we can tackle next are how might you use this
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How do you
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years?
Is it Cori?
Is it AHRQ?
So, is it MedPAC
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there who may meet the criterion, but who actually would
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But, it seems to me
I think Medicare is
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MR. HACKBARTH:
various types.
we can do there.
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Right.
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MR. WINTER:
There are
Yeah.
-- on an inpatient basis.
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MR. HACKBARTH:
Yeah.
point.
within HMOs.
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Jon and I were talking about the other day and the
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unconstrained fee-for-service?
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Jay.
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inform care.
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data and then merged these data with lots of other data
important.
For example, I
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to us?
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very well.
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contribution.
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It means that
But, this
DR. NAYLOR:
recommended next steps.
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harmful, and to the extent that we can define for whom and
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I think there is a
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of pocket.
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more for low value, I think they need to know that this is
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a low-value service.
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another year of data or two using the same method, and also
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talk to them about concerns they might have about how noisy
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interesting.
But, it could be
DR. NAYLOR:
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services.
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DR. CROSSON:
I'm
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number one.
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work that's ongoing and new ACO models and the like, I
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look at, maybe some larger subset of the 300, and then
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reform.
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[Laughter.]
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DR. SAMITT:
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I'm kidding.
I think --
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DR. SAMITT:
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And so let's
This is critical.
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And what
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improve health.
So I don't know if there's a way to tie this
hand in hand.
DR. CHRISTIANSON:
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more money."
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comments?
DR. NAYLOR:
Obviously
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studies that have done that, you know, just a lit review of
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I have no doubt
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And
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Act.
And so I think that there's a real ethical
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strong as well.
And for
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problem is.
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easy to do.
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MR. HACKBARTH:
Okay.
Thank you.
Great work.
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care.
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[Pause.]
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DR. STENSLAND:
All right.
Good afternoon.
episode.
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spending metrics.
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in value.
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VBP scores will receive more than 2 percent back, and those
spending metrics.
In 2017 and in
This essentially
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after discharges.
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category of discharge.
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if quality is equal.
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use.
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We find that at
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inpatient episode.
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rates, and in that case we said that was true and there
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should be an adjustment.
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In this slide
Many high-
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And a question is
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correlation.
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small very small and that the sign of the correlation can
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We also looked
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DR. CARTER:
on the right).
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makes up 26 percent.
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payments.)
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$3,400 for the top quartile hospitals and $2,400 for bottom
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over threefold for IRF spending and over sixfold for LTCH
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The
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spending.
We don't
Controlling
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under it.
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spending.
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We already
Yet, as Jeff
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providers.
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Some
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Medicare.
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In addition, the
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share to up to 50 percent.
hospital measure.
A PAC measure
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episode spending.
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use.
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condition.
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beneficiary.
measures.
Although
Typically,
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Fee-for-
We could
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and readmissions.
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volume of episodes.
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population.
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volume of episodes.
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per episode.
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of service.
policy.
for SNFs.
Rates for
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as the population.
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administer.
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The
We know that
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each other.
So
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We'd like to
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DR. NAYLOR:
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Okay.
Options
Thank you.
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payment model 3?
DR. CARTER:
days.
initiative is voluntary.
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risk.
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What we were
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MR. GRADISON:
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DR. STENSLAND:
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MR. GRADISON:
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DR. STENSLAND:
And
That's all.
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MR. GRADISON:
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DR. NERENZ:
Is the hospital
And we're
In this measure,
Can we get
But
Thank you.
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readmission?
DR. CARTER:
No.
DR. NERENZ:
Okay, good.
DR. CARTER:
[Nodding head.]
DR. NERENZ:
Okay.
MS. BUTO:
One is
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rates.
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admissions?
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Do
And the
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DR. CARTER:
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MS. BUTO:
DR. CARTER:
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MS. BUTO:
Yes.
Admission rates.
fast?
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DR. STENSLAND:
No.
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like?
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DR. MILLER:
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least you can inject some feeling into how much you amplify
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hospitals.
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bundling stuff
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MS. BUTO:
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MR. HACKBARTH:
[No response.]
MR. HACKBARTH:
DR. SAMITT:
Okay.
Round 2.
Craig.
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three.
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And the
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powerful solution.
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population health.
MR. HACKBARTH:
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DR. STENSLAND:
It
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readmission penalty.
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of it.
small.
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discharge performance.
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DR. STENSLAND:
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Like the
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They
thing.
It may be something we
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MR. HACKBARTH:
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DR. SAMITT:
Okay.
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MR. HACKBARTH:
If you are
design or indifferent?
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DR. SAMITT:
neither is good.
acute.
outcome?
So while
MR. HACKBARTH:
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they conflicting?
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of payment incentives?
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Other -- Herb.
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MR. KUHN:
Are
Should
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that.
you've got now with the three of them -- that is, the
that is going to grow next year to 5.75, and the year after
So it's
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work together.
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So it would be
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understand.
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To
I just
MR. HACKBARTH:
Round 1.
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clarifying questions?
[No response.]
MR. HACKBARTH:
4
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Round 2.
then Jay.
MS. UCCELLO:
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Obviously, in the MA
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We heard
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Patients want to
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think even with current guidance going on, benes are still
making choices that may not align with where they are being
recommended to go.
DR. HOADLEY:
But I
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I know at
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value and sort of having certain Star levels and just for
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forward.
Here's money.
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MR. HACKBARTH:
the pending SGR bill is that at least they made some effort
down, and I think maybe some of the same sort of work could
point.
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Warner.
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MR. THOMAS:
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improved.
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to accomplish.
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bundled program?
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DR. MILLER:
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I guess, as I read
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in the area, and I would just add to Jack's list, there are
The Stars
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noise out there that people are less clear, and what was
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soon, and I'm not sure how to even get involved in it.
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Why
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together.
have too many bells and whistles, put them in one place, or
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no resistance to that.
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MR. THOMAS:
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priority.
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So
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MS. BUTO:
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So, if
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this, and then the mechanism for getting the money to them
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actually are.
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MR. HACKBARTH:
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the beginning.
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have.
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DR. MILLER:
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this ongoing dilemma, and you hear it here all the time,
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example.
complicated.
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together.
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MS. BUTO:
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that, Mark.
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DR. MILLER:
[Off microphone.]
I hear you.
DR. NERENZ:
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But, I
discussion.
But, as I went through the chapter, in reading
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it, I was looking for the point where we'd say, well, how
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Medical Homes.
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Kathy's question.
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Do hospitals
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Meaning, do hospitals
world to be?
alternatives.
DR. NAYLOR:
points.
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MR. HACKBARTH:
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[No response.]
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Okay.
period.
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DR. MILLER:
comment slide?
Thanks.
MR. HACKBARTH:
[Pause.]
MR. HACKBARTH:
[Laughter.]
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MR. HACKBARTH:
Go ahead, George.
You're
special, so we'll --
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Thank you.
I just stood up
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--
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[Laughter.]
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MR. HACKBARTH:
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[Off microphone.]
But, Glenn has been a great
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Chairman.
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stand and rise and thank you for your great, great service
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[Applause.]
2015.]
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B&B Reporters
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PUBLIC MEETING
COMMISSIONERS PRESENT:
GLENN M. HACKBARTH, JD, Chair
JON B. CHRISTIANSON, PhD, Vice Chair
SCOTT ARMSTRONG, MBA, FACHE
KATHY BUTO, MPA
ALICE COOMBS, MD
FRANCIS JAY CROSSON, MD
WILLIS D. GRADISON, MBA
WILLIAM J. HALL, MD
JACK HOADLEY, PhD
HERB B. KUHN
MARY NAYLOR, PhD, RN, FAAN
DAVID NERENZ, PhD
RITA REDBERG, MD, MSc, FACC
CRAIG SAMITT, MD, MBA
WARNER THOMAS, MBA
CORI UCCELLO, FSA, MAAA, MPP
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AGENDA
PAGE
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P R O C E E D I N G S
[8:30 a.m.]
MR. HACKBARTH:
Good morning.
services.
MS. RAY:
Good morning.
Medicare's payment
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In one
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For two
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drugs.
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We focus
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price in 2013.
oncologists in 2013.
oncology services.
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can affect.
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bundle.
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180-day follow-up.
180-day
outpatient
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hospice is lavender.
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In addition to spending on
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services.
slide.
spending.
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So I'd like to
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through 6.
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During
This is another
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drugs exist.
coordination.
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In our June
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all services.
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the bundle.
type of payment.
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The
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narrowly defined.
bundling.
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This would
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certify.
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involved.
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straightforward to implement.
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successful bundle.
MD
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similar to a DRG.
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The
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is that paying for oncology drugs via ASP plus some add-on
The insight
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discontinue treatment.
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savings.
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practices.
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radiology.
it.
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initiating chemotherapy.
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in spring 2016.
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A subset of the
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payment.
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The PBPM is
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The PBPM
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month payments.
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If the
The amount of
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incentive.
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patients.
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MR. HACKBARTH:
Thank you.
This is really
interesting.
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talk about.
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That is easier to
Thanks.
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breast cancer.
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MS. RAY:
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cancer yet.
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forward.
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MR. HACKBARTH:
Okay.
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of the episode.
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MS. RAY:
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on.
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MR. HACKBARTH:
questions.
Okay.
So Round 1 clarifying
prospective payment.
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MS. SMALLEY:
Sure.
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of the change is that the drugs are paid at ASP plus zero,
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It's kind
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MS. BUTO:
On the first
course of treatment.
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MS. SMALLEY:
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MS. BUTO:
Okay.
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MS. SMALLEY:
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MS. BUTO:
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DR. NERENZ:
Right.
Gotcha.
On Slide 6, please.
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be.
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inpatient.
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MS. RAY:
Is there just an
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period.
DR. NERENZ:
MS. RAY:
Okay.
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MS. RAY:
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DR. NERENZ:
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Right.
It could, yes.
The trigger
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MS. RAY:
Yes.
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DR. NERENZ:
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MR. HACKBARTH:
Okay.
So, Nancy, could I just make sure
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I understood that?
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denominator --
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MS. RAY:
MR. HACKBARTH:
Yes.
-- even if they've died during
the period.
MS. RAY:
or 6.
MR. HACKBARTH:
MS. RAY:
MR. HACKBARTH:
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MS. RAY:
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MR. HACKBARTH:
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So --
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Okay.
Right.
But then they don't influence the
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MS. RAY:
Right.
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MR. HACKBARTH:
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MR. GRADISON:
Okay.
There are two pilots, Case Study 3
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was in 2011, and the other united one was between 2009 and
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2012.
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MS. RAY:
I can't
MR. GRADISON:
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MS. RAY:
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MR. GRADISON:
Okay.
Yeah.
I'm not sure whether you are
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telling me that you know all that you would like to know
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applied.
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I just
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MS. RAY:
Okay.
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MR. GRADISON:
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so forth.
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52 percent?
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Can it both be
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MS. RAY:
MR. GRADISON:
MS. RAY:
It is.
[Laughter.]
MS. RAY:
that.
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Okay.
10
Yes, it is.
Yes.
I know.
That's okay.
It really is 52 percent.
MR. GRADISON:
them.
All right.
Thank you.
MR. HACKBARTH:
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DR. NAYLOR:
On the 21 percent,
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that right?
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MS. RAY:
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DR. NAYLOR:
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MS. RAY:
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DR. NAYLOR:
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20 percent.
20 percent.
Yes.
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DR. NAYLOR:
MS. RAY:
DR. NAYLOR:
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MS. RAY:
The only
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which gives them one bill for the entire year of services,
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DR. CROSSON:
The
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first one, from the case studies that you looked at and
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protocols?
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MS. RAY:
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MS. SMALLEY:
Yeah.
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Right.
Did I
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model.
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Yeah.
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MS. SMALLEY:
right.
MR. HACKBARTH:
MS. SMALLEY:
That's correct.
MR. HACKBARTH:
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oncology case.
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DR. CROSSON:
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DR. CROSSON:
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[Laughter.]
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DR. CROSSON:
Wait.
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Is there
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MS. RAY:
learned there.
the demonstration.
this year.
they applied some of what they learned from that demo into
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DR. SAMITT:
Thanks, Nancy.
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for you.
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Is it possible to
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MS. RAY:
MS. RAY:
Right.
DR. SAMITT:
oncologist influence.
MS. RAY:
Yeah.
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DR. SAMITT:
My second --
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DR. MILLER:
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MS. RAY:
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MR. HACKBARTH:
We could
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DR. SAMITT:
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oncology is outpatient.
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DR. MILLER:
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avoidable or not.
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DR. SAMITT:
I'm not
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DR. MILLER:
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on this, though.
DR. SAMITT:
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DR. MILLER:
[Laughter.]
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tease out where these things are coming from and then put
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MR. HACKBARTH:
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MR. KUHN:
Clarifying questions?
Yeah.
And
Herb.
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thus far.
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MS. RAY:
Do we
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MS. SMALLEY:
Yeah.
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MS. RAY:
Right.
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approach, they found that total cost went down, but drug
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costs went up, and that was a little bit contrary to what
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DR. COOMBS:
give the case study for Blue Cross/Blue Shield, and with
Slide 5, it's been said that a lot of the cost -- well, the
let's see.
What I was
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the Part B.
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way that the bundling breaks out that it's more equitable
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know, it may be that ASP plus six and you add the
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services.
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drugs.
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Because, you
DR. MILLER:
So
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professional fee.
DR. COOMBS:
Right.
DR. MILLER:
to be around that.
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DR. COOMBS:
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DR. COOMBS:
What
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fees?
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MR. HACKBARTH:
Yeah.
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discussed.
talking about.
DR. COOMBS:
MR. HACKBARTH:
DR. COOMBS:
Right.
I don't know --
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administering agent.
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aggressive.
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MR. HACKBARTH:
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DR. COOMBS:
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Yeah.
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cost under the bundle, that would move them still a further
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Most
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DR. COOMBS:
Right.
all of those and just go with what does it look like for
DR. MILLER:
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for specialties that you named and anyone else that you're
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maybe that helps you get your head around the equity issue
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information.
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that I won't bore you with and that you know well too.
then you will have the overlay of the bundle, and then you
DR. COOMBS:
And
question.
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measure, however.
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navigation services.
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MR. HACKBARTH:
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DR. REDBERG:
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Okay.
Continuing Round 1.
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This was a
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DR. REDBERG:
MS. RAY:
DR. REDBERG:
Yes.
Do you have any data on what
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MS. RAY:
no, I don't.
That, I don't --
DR. REDBERG:
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MS. RAY:
with something.
Right.
Yeah.
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MR. ARMSTRONG:
What is the
Is it this weird
Is it
We talk a lot
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outcomes.
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MR. HACKBARTH:
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MR. ARMSTRONG:
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DR. MILLER:
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above?
is in front of you.
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sales price.
We also had
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oncology.
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that.
guys.
There is this
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you do?
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MR. HACKBARTH:
I'm done.
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done, Mark, and that last point is, I think, important and
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what the right care is, let's look at the average cost and
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decentralization.
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And that to me
Let's decentralize
It's a
MR. ARMSTRONG:
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change that.
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MR. HACKBARTH:
Yeah.
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MR. ARMSTRONG:
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I was asking --
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MR. HACKBARTH:
MS. BUTO:
avenue to explore.
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that way.
There's a lot of frustration around -- and we
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of let the practice figure out whether they need that drug
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Whenever
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we talk about LCA, it's funny that the issue of the high-
cost hep C drugs comes up, and yet I'm not sure that they
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And it also
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MR. HACKBARTH:
I do think we need to be
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new drug comes out that has a very high price tag that
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MS. UCCELLO:
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So,
paying more than they would have otherwise, and some less,
if it were -- right?
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MS. SMALLEY:
Right.
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way.
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MS. RAY:
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imagine.
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MS. UCCELLO:
DR. MILLER:
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Round 2.
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DR. HOADLEY:
And so that
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would still be done the way it is, and the shared savings
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would be separate.
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MS. RAY:
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DR. HOADLEY:
Okay.
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MS. RAY:
Do
DR. HOADLEY:
MS. RAY:
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Okay.
DR. HOADLEY:
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Would you get a similar pie chart for each of the three?
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MS. RAY:
Is it
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here.
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cancer patients and is higher for the colon and lung cancer
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patients.
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But what I can tell you is that the average cost per
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DR. HOADLEY:
MS. RAY:
DR. HOADLEY:
MS. RAY:
Right.
Part D drugs.
dollars.
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DR. HOADLEY:
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realize.
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MS. RAY:
Right.
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DR. HOADLEY:
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MR. HACKBARTH:
I'll leave my
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MR. THOMAS:
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MS. RAY:
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that.
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MR. THOMAS:
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surgical intervention?
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MS. RAY:
MR. THOMAS:
MS. RAY:
Right.
10
If the patient is
--
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MR. THOMAS:
Then --
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MS. RAY:
13
MR. THOMAS:
14
DR. CHRISTIANSON:
That's right.
Okay.
Thank you.
Yeah, also on the CMMI, the
15
way you wrote that up, it seemed like it's kind of more in
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that work?
Do we know
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MS. SMALLEY:
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DR. CHRISTIANSON:
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From that
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I guess that's
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one-sided.
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MR. HACKBARTH:
ratio, to use the --
MS. RAY:
MR. HACKBARTH:
Yes.
-- ACO language, 4 percent if the
minimum savings.
DR. CHRISTIANSON:
MR. HACKBARTH:
All right.
Okay.
Thanks.
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MS. RAY:
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visits.
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provider types.
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inpatient
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MR. HACKBARTH:
make sense.
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DR. REDBERG:
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And so
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that was not necessarily the best outcome base, and that
MR. HACKBARTH:
DR. CROSSON:
I think,
think what I heard Nancy say was that it's likely that the
And I
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results.
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caregivers --
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DR. NAYLOR:
15
[Laughter.]
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DR. CROSSON:
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drugs, at least.
DR. NERENZ:
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DR. CROSSON:
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DR. NERENZ:
17
MR. HACKBARTH:
18
is it on this point?
19
have --
20
DR. NAYLOR:
21
approach.
22
stories.
It's broad.
Yeah.
Broad, good.
Go ahead.
Mary, Bill,
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costs, et cetera.
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are changing.
DR. HALL:
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What
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that any of us in the room here who reach that age have at
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largely oncologists.
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with cancer will say they don't have to ask the doctor when
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patient in psychotherapy.
22
woman said that she had decided with her oncologist to take
The
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when she asked when the next appointment would be, the
drug or something."
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broader approach.
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hasn't already.
15
MR. KUHN:
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couple of reasons.
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And I just
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DR. COOMBS:
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Breast
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Whereas, as
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and saying, "In our hands, the national data says this in
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that they are high volume and they see a lot more and they
do a lot more.
10
region.
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MR. ARMSTRONG:
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[Laughter.]
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MR. ARMSTRONG:
In fact, I think go
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right?
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trying to solve?
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incentives?
Walmart is
This is happening
It
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to?
14
And second, is
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this evaluation.
19
DR. MILLER:
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all the risk stuff, and you made a similar comment, right?
22
[Laughter.]
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DR. MILLER:
apologize to Kathy.
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I almost took
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MR. HACKBARTH:
I'd like
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payment system.
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It isn't just
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system."
that.
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So I don't
MR. ARMSTRONG:
that offline.
Yeah.
11
[Laughter.]
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DR. REDBERG:
13
MR. ARMSTRONG:
14
degree I know about this, there are very expensive and not
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a bundle, necessarily.
21
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spending.
MR. HACKBARTH:
identify other big issues that they would like Nancy and
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So my targeting for
12
Jack.
13
DR. HOADLEY:
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a mini bundle in the sense that it's among drugs that are
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of bundles.
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On the
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incentives?
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bundle for treating breast cancer, okay, but now how many
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Maybe that's
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Do we want
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lined up with the cost of each service that has their own
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attached to the bundle now, the patient has their own set
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of odd incentives.
15
regardless of treatment.
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MR. HACKBARTH:
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points, Jack.
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Breadth has
These are
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MR. HACKBARTH:
Exactly.
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DR. HOADLEY:
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MR. HACKBARTH:
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DR. HOADLEY:
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get in here.
Okay.
Exactly.
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and Rita.
DR. REDBERG:
MR. HACKBARTH:
DR. HOADLEY:
MR. HACKBARTH:
Warner.
MR. THOMAS:
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Okay.
Okay.
I think the
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there could be, going back to the point made earlier, that
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aligned.
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direction to go.
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helpful.
MS. BUTO:
pursued.
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oncology.
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the practice.
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provider groups.
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think your point, Glenn, that what isn't in, you're going
anticipate yet.
I mean, I just
opportunities to go after.
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more cost with the per, the monthly fee, and one-sided
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risk.
At
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outcome.
DR. NERENZ:
Okay.
If
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I couldn't tell
So future.
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is its essence.
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bundling demo.
dominant I --
DR. SAMITT:
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bundle guy.
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stinting issue?
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worried.
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But
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directions.
the bundle, and the bigger the bundle, the more vague it
gets.
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Because
Is it
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DR. REDBERG:
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[Laughter.]
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DR. REDBERG:
So
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me the best care is, you know, the best treatment and then
And to
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oncology in particular.
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we're going to wait for the studies, which then take longer
survival.
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for, but it's not always a very strong evidence base, and
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different reasons.
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have drugs that we can give patients, and that it's not a
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very sorry, but you are at the end of life, but I am still
You know,
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think it's certainly not the only reason, but right now the
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hospital.
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DR. CHRISTIANSON:
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consistent with what Dave said and certainly with what Rita
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said.
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effect on quality.
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Medicare dollar.
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the dollar.
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Katelyn.
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the future.
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Would
Okay.
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DR. LEE:
This morning, we
Good morning.
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past discussions.
MA
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areas.
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service use.
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service spending.
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If beneficiaries
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and Miami.
bid.
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the
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higher-cost option.
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MA bid.
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$100 or more.
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market areas.
We picked
But
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discussion.
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efficient models.
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design questions.
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set?
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Which Medicare
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Fee-for-service
This
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Is it fair for
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premiums?
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In particular, how
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program.
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would not guarantee that they are going to make the best
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It requires
Moreover,
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choice.
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In fact,
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Such
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decisionmaking.
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possible.
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In making the
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MA.
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What
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The
quality.
diagnoses.
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DR. LEE:
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not.
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MR. HACKBARTH:
Thank you.
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We use the
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use.
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fee-for-service.
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"Traditional Medicare"?
"The government-
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descriptor.
I don't know.
But it seems to me
You pay a
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other alternatives.
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best that I can come up with, but you can tell why I'm not
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[Laughter.]
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MR. HACKBARTH:
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DR. SAMITT:
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So in the materials,
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the chapter that you had sent around, you talk about the
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3 percent.
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MR. ZARABOZO:
[Pause.]
DR. HARRISON:
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Advantage.
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DR. SAMITT:
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switched --
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DR. HARRISON:
Right.
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MR. HACKBARTH:
-- from fee-for-service to
DR. HARRISON:
Correct.
DR. SAMITT:
Okay.
Thank you.
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Does
Risk adjustment
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DR. HARRISON:
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DR. SAMITT:
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MR. HACKBARTH:
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DR. COOMBS:
Yes.
Okay.
Thank you.
Clarifying questions?
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with coding?
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MR. ZARABOZO:
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DR. COOMBS:
I mean, if you
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maybe more robust EHRs, EMR on one side versus the other.
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to be different.
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MR. ZARABOZO:
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depression.
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schizophrenia.
depression that feeds into the HCC risk assessment that can
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MS. UCCELLO:
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here.
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MR. ZARABOZO:
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MS. UCCELLO:
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MR. ZARABOZO:
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MS. UCCELLO:
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Is there a lot?
Is there a little?
DR. LEE:
So if you are
wide range.
You know, you can have -- the difference between the lowest
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MS. UCCELLO:
So that I think
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threshold?
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fee-for-service areas.
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deal is this?
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MR. ZARABOZO:
Cook.
I assume there
Are
Okay.
How big of a
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MS. UCCELLO:
Okay.
report, but did we -- for the markets that have all three
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MR. ZARABOZO:
Fee-for-service, traditional
Medicare --
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MR. THOMAS:
Traditional Medicare.
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MR. ZARABOZO:
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MR. THOMAS:
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MR. ZARABOZO:
Without ACO --
Correct.
-- probably -- I don't have the
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isn't a lot.
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And I
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more.
MR. HACKBARTH:
MR. GRADISON:
Excuse
Continuing Round 1.
Looking at page 9 in the meeting
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but you compared 2015 data because it's available with 2013
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change as more recent data -- that is, that data for 2015
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DR. CROSSON:
It's sort
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DR. MILLER:
sorry.
I wasn't
So why would
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ACO, and there's some looking down the road to using, you
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history.
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That's
to that, which then might mean that the ACOs have the same
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incentive as an MA.
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MR. ZARABOZO:
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models, like the NextGen that David talked about, they are
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incentive to code.
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DR. CROSSON:
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DR. MILLER:
That's
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synchronization.
MR. ZARABOZO:
consistent coding.
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MR. HACKBARTH:
Okay.
Okay.
questions?
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[No response.]
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that has the various options for how to set the basis of
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DR. MILLER:
Okay.
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the issues and sort of talked out with all of you about how
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is she came down and she and Glenn had an exchange, and we
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to.
okay?
You know it's almost two times that in Miami, and you know
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exchange that Glenn and Kate were having, which is, well,
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should pay the same premium because they don't have any
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through.
And you
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when you get into this where are we going to set the
you settled out -- and I hate to speak for her not being
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here, but I think Kate was of the mind you pay the same
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way you could resolve it, and Kate and Glenn were talking.
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service in Portland.
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101, and then notice the third row of that premium, the
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And
So, in Miami,
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make.
You could
And
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more complicated.
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Second question:
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And I guess the very last sentence I'll say -well, I'm done.
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DR. NERENZ:
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point.
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right?
statement?
acute whatnot.
Is that a fair
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important?
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DR. MILLER:
Is that even
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I'm getting the real engaged looks from you that I want to
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get.
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[Laughter.]
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DR. MILLER:
Okay.
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you set -- how would you set the premium and what would
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a little bit and say, you know, what premium would the
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you know, the purchase and the choice of Medicare, and does
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So if I'm in Miami-
And the
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MR. HACKBARTH:
types of incentives.
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DR. MILLER:
I'm
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microphone].
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DR. SAMITT:
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MR. HACKBARTH:
this point.
well.
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beneficiaries.
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in Miami.
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DR. SAMITT:
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DR. MILLER:
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exercise.
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adjusted numbers?
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Okay.
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Should they be thinking of these as wageBecause these are not -- is that -- no.
Okay.
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MR. THOMAS:
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correct?
relatively close?
Is that
DR. STENSLAND:
I think
the ACO and the fee-for-service are maybe the lower cost
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MR. THOMAS:
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that, with the right incentives, could the ACO and MA model
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We keep
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MR. HACKBARTH:
providers.
another.
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in traditional Medicare.
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MA to succeed.
to be real blunt.
MR. THOMAS:
Right.
The question
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what not.
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So in
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for-service model.
DR. HOADLEY:
right way.
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jump a step above that, but it may also make sense that we
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some way that ignores the fact that it may come in benefits
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stuff.
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incentives?
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MR. HACKBARTH:
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geographically.
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You
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DR. HOADLEY:
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DR. LEE:
So it's supposed to be
DR. HOADLEY:
DR. LEE:
Right.
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DR. HOADLEY:
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DR. LEE:
Strategy.
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strong to MA benchmarks.
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DR. HOADLEY:
So I misspoke a little --
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MR. HACKBARTH:
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DR. LEE:
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small.
DR. HOADLEY:
MR. HACKBARTH:
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DR. MILLER:
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DR. HOADLEY:
Yeah.
Okay.
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is as a package of services.
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cost.
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It might mean
So that's kind of
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don't have -- it seems like there's even less logic for the
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MR. HACKBARTH:
rest of America?
DR. HOADLEY:
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MR. HACKBARTH:
MS. UCCELLO:
MR. HACKBARTH:
MS. UCCELLO:
[Laughter.]
MS. UCCELLO:
Cori.
Okay.
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the thought around that was maybe not, but I think we need
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DR. MILLER:
coming along.
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MR. HACKBARTH:
DR. MILLER:
Go ahead.
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in fee-for-service.
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to do this.
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minute.
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style?
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MR. HACKBARTH:
Yeah.
The
And
If
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meeting.
Scott.
MR. ARMSTRONG:
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direction.
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category that is the big issue that jumps out for me.
wonder.
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as a program?
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MR. HACKBARTH:
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fact that you have much less variation in MA bids than you
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Yeah.
issue into choices the beneficiary has, and they look like
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mean, I don't know what that looks like, but why are we not
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MR. HACKBARTH:
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Okay.
Warner.
minutes or so left.
MS. BUTO:
DR. SAMITT:
MR. HACKBARTH:
DR. SAMITT:
Okay.
We've got 20
Sure.
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Cori now.
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I feel like
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DR. LEE:
DR. SAMITT:
DR. LEE:
DR. SAMITT:
Yes.
DR. LEE:
DR. SAMITT:
MS. BUTO:
Uh-huh.
Great.
I was
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I think what
Is our goal to
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certain level.
contribution.
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MR. HACKBARTH:
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DR. CROSSON:
Let's see.
Yeah.
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think for the same reason that Kathy just said -- which
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that.
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equity.
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we sort of back out that piece and just say we are going to
care, but just the input cost, and we take out the outlier
and we look more at, say, from the 25th percentile to the
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You will
As David
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MR. THOMAS:
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MR. HACKBARTH:
person at least.
[No response.]
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MR. HACKBARTH:
Okay.
final observation.
I know this is
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Even among
It has a
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more.
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bills of their own, and they may not have very generous
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provider.
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kids pay for it, and that's not what they've got.
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And
B&B Reporters
701 Copley Lane
Silver Spring, MD 20904
301-384-2005
So to
The
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then when it's their turn, the rules are going to be very
different.
So they are
I've
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good work, but it's also in part about values and I think
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[Laughter.]
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MR. HACKBARTH:
But I do think
I am done.
B&B Reporters
701 Copley Lane
Silver Spring, MD 20904
301-384-2005
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[Pause.]
MR. HACKBARTH:
Nobody.
We are adjourned.
you all.
[Applause.]
adjourned.]
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B&B Reporters
701 Copley Lane
Silver Spring, MD 20904
301-384-2005
Thank