Health care experts from across the field-- industry insiders, Stanford Health core faculty members, policymakers-- are gathered in Menlo Park, CA, to discuss what reforms are needed in the health care system. Follow the conference here. In the next week all presentations and videos will be available online.

The conference agenda.

Stanford Health Policy core faculty member Victor Fuchs welcomes hundred plus attendees. Fuchs has co-directed the FRESH-Thinking Project with Ezekiel Emanuel. Emanuel stepped down from the Project to join the Obama Administration earlier this year.

President and CEO of the Blue Shield of California Foundation Crystal Hayling makes opening remarks, discussing the history of the FRESH-Thinking Project on Health Reform. "We want(ed) to get a lot of smart people in the room, and we wan(ed) them to disagree with one another ... (Fresh Thinking) has done that admirably." Concludes with: "I hope that we will continue that spirit today ... disagree with one another."

Claude Steele discusses the development of FRESH-Thinking within Stanford's Center for Advanced Study in the Behavioral Services (which Steele directs). He says of today's event: "it's often noted that genius or success when the prepared mind meets up with opportunity." Introduces first speaker, John B. Shoven, Director of the Stanford Institute for Economic Policy Research (SIEPR).

Shoven begins talk by asking "is it possible to put health care on a diet?" He says cost control and universal coverage are not necessarily in conflict. Goes through logistics of who the uninsured are (1/4 poor, more than half are young) and what the current taxation approach is. Shoven says two myths persist in health care dialog: shared responsibility and the middle class not having to shoulder health care costs. Shoven's take aways are "it's not necessarily that we should have new value added tax. It's that we should have a dedicated tax ... We should not separate the benefits from the costs."

UC Berkeley School of Public Health Dean Stephen Shortell speaks next. Shortell was in Washington, DC, on Monday for President Obama's press conference on the need for comprehensive health care reform. The Blue Cross of California Distinguished Professor of Health Policy and Management begins his talk by saying the American health care delivery system "leaks value." He shows a chart showing higher spending not associated with higher quality of care-looks at state-by-state comparison. California "not doing so well."

The rubber meets the road in the delivery of health care. Shortell says the underlying issue is "how can you get more providers in this country to aggregate up ... to deliver the kind of care that is going to be needed." The current organization doesn't work, Shortell says, and instead he looks at the potential of accountable care organizations (ACOs)-- entities that are clinically and fiscally accountable for the entire continuum of care that patients may need. An ACO has only two jobs, according to Shortell, to continuously improve value of the care it delivers and to provide the evidence on this.

Stanford Health Policy director Alan Garber looks at "value conscious biomedical innovation." He brings in the role of comparative effectiveness research (CER) in understanding the efficacy of new drugs and technology, and how CER could guide coverage decisions.

Garber mentions an upcoming report he's doing on CER in prostate cancer treatment. As it stands there's no information "to say that one approach is better than another in terms of survival," he says, only that the treatments vary with side effects and costs.  His report maps out these variances-the idea being that the consumer should have access to all options and the varying side effects and costs associated with each treatment.

With the backdrop of CER, Garber says this could be a golden era for the right kind of innovator-the innovator who focuses on higher value.

Judge Robert Maclay Widney Chair and Professor at the University of Southern California Leonard Schaeffer looks at the future of health care reform in his post-lunch talk. He paints the picture in Washington and the general public sentiment. A big barrier, Schaeffer says, is the public is split in its willingness to pay for universal coverage-- a Harvard/Kaiser poll shows 49 percent of respondents are unwilling to pay higher taxes so more Americans could receive insurance (47 percent would pay more).

But, Schaeffer says, this is a political environment for serious changes in health coverage. Countered by this era of transformation, though, is that to date real health care change has been prevented by those very political players. The general sentiment among politicians, he says, has been to express empathy and then do nothing.

The piecemeal change that is most politically palatable is also the riskiest, Schaeffer says, instead we have to "transform the underlying delivery system." Schaeffer closes his talk by saying it is highly likely we'll see health reform passed but the question is will it help or cause more problems? "And based on my years and years (in this area)... I have no idea."

Sharon Levine, Associate Executive Director of the Permanente Medical Group, introduces the physicians and reform group. Each doctor represents a different organization type: Robert Feldman with Hill Physicians Medical Group; Richard Slavin is CEO of Camino Medical Group and Philip Pizzo is Dean of the Stanford School of Medicine.

Feldman starts things off saying it would be a shame to discard the independent physician association (IPA) model. Drawing on the Hill Group's success, Feldman says his organization's approach is "always looking for the best of breed ... continuous improvement" in the group model. This continuous improvement guides its focus on efficiency, leverage, system-wide electronic health records, depth of management, quality standards and regionalization of specialty care. Feldman closes by saying ""we try to inculcate behaviors to benefit the group ... We think group practice is the future."

Slavin follows up by painting a portrait of the 21st century physician pool-more women, a greater focus on working to live (than living to work). Computer literate and used to report cards and conforming to best practice guidelines. "They also want to work as part of a team" in a society with universal coverage where they can provide optimal care to everyone. But they also don't want this universal coverage to translate in decreased compensation.

Slavin then focuses on Camino Medical Group's approach to giving care. Its aim is to minimize hospitalization and manage chronic disease. This translates to self-care and "really emphasizing patient education ... avoiding visits to the doctor." Slavin sees electronic technology as playing a critical role-patients can educate themselves with online resources and will continue to do this into the future.

With Medicare costs becoming unmanageable, Slavin draws on the difficulty of his group's ability to support this group. Camino Medical Group cares for about 600,000 and will have to close its doors to Medicare reimbursement. "Currently we're supported by cost shifting the employers, the individuals paying for HMOs that are supporting our ability to care for Medicare population." But, Slavin closes with, ""our group has adapted continuously over the past 80 years and I'm sure we will in the future"

Pizzo takes on the physician problem from the research institution side and the connectivity between research and outcome. There are 130 medical schools in the U.S today and more and more these schools are training specialized physicians. A big reason for this is the perverse incentives. The top choices of residencies in the past year-dermatology, emergency medicine, etc.-"you don't find the primary care specialty. Internal medicine is now less than twenty percent."

Much of this relates to the perverse incentives, Pizzo says, given that primary care doctors are paid less than specialty physicians. "All of our incentives are perversely aligned." Pizzo points out this is true more broadly-"we reward doing more and getting less for it ... who's going to make the bottom line for the institution. That set of perverse incentives need to change."

The public and reform panelists have spent much of their time responding to earlier talks. In particular panelist Gilbert Ojeta, Director of the California Program on Access to Care, and Sandra Shewry, President and CEO of the Caliofnira Center for Connected Health, take issue with John Shoven's statement that shared responsibility is a myth. Shewry says: we "cannot underestimate the power of language" in shared responsibility.

Shewry then drills into the importance of government employing social marketing to change public thinking. She highlights the power of the public in the anti-smoking campaign "where we had a societal goal, a whole industry had to be assaulted ... say what was wrong and then paint the path to a better tomorrow."

The panel is also quite focused on California-specific reform. Ojeta points out the giant role immigration will play in focusing the health care reform debate in this state, something Shewry agrees with given the high number of immigrants in California.

Final panelist Lucien Wulsin, president of Insure the Uninsured Project, notes that California-with its seven million uninsured-is poised to be a net winner financially under health care reform. "We need to think about that and how important that is," Wulsin says.

Fuchs delivers keynote address summing up his findings working with FRESH-Thinking. He points out that we must ask what is wanted in health care reform.
Drawing on Shoven's earlier talk, Fuchs makes clear "this country has been unwilling to bite the bullet of subsidization and compulsion" for universal health coverage.

Fuchs thinks we have no way of knowing what health reforms will be made with this new administration-"What is likely???" reads his slide which he explains "I put down three question marks because I don't want to overdo it. I'd be ware of anyone who (thinks they) can tell you (what reforms are going to happen)." Instead, Fuchs says, "what we can talk about are possibilities."

Fuchs goes through all items on the table-bending the health expenditures curve to a government health insurance company to a cap on tax-free employer contributions to health insurance, etc.

He concludes with what his guess for health reform is. "Remember it is a guess," he cautions. Something will pass-- a deal will be cut-- but "I'm not optimistic that it will even be close to what is needed."

"I've been pessimistic before-- of course I've been right before."

The way things could change are if there's a catastrophic event like a pandemic flu or a sharp rise in unemployment. Or if Senator Ted Kennedy were to die-it could have a rippling effect where Congress might rally to overhaul the system in honor of Sen. Kennedy's efforts.
 
On the flip side Fuchs says his list for what will delay or kill health care reform is longer-current items like a battle over Supreme Court justice, bailout issues, crises in Iraq/Iran/Pakistan/Afghanistan. China not buying U.S. bonds, etc.

Why the chasm between what is likely and what we need? Fuchs says this is a question that has bothered him for a long time-people and organizations prefer the status quo. The system is also not bad enough where we will actually change things.

"The one thing that I reject is that we can't do it because of political feasibility," Fuchs says, going into a historical list of American policies that should have never had the political feasibility to get through.

Fuchs thanks everyone to great applause.