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From YouTube: Medicaid Innovations
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A
I'm,
a
state
representative
from
the
state
of
Alabama,
where
I
chair
the
help
committee
and
I'm
also
vice
chair
of
NC
SLS,
Health
and
Human
Services
Committee
Medicaid,
continues
to
take
up
a
large
portion
of
all
of
our
state
budgets
and
remains
one
of
the
biggest
challenges
for
lawmakers
in
terms
of
anticipating
and
controlling
costs.
Today
we
will
hear
about
recent
state
innovations
such
as
payment
and
delivery
reforms
that
show
promise
in
terms
of
helping
States
improve
program
efficiencies
which
I
know
is
very
important
to
all
of
us.
A
Today
we
have
the
privilege
of
being
joined
by
our
panelist.
Senator
bond
is
Anderson
from
Oregon
senator
Watson
from
Tennessee,
and
our
moderator
Kathleen
Nolan
Kathleen
is
a
managing
principal
at
health.
Manage
management
associates
and
brings
with
her
a
wealth
of
Medicaid
reform
and
innovation
expertise.
A
She
previously
held
the
position
of
Director
of
state
policy
and
programs
for
the
National
Association
of
Medicaid
directors.
She
did
that
for
12
years
and
she's
also
been
a
division
director
of
health
at
the
National
Governors
Association
senator
Bonnie's
Anderson
is
a
registered
nurse.
She's
been
an
oregon
state
senator
since
2004
as
a
county
public
health
nurse
she's
worked
in
a
variety
of
areas,
with
drug-addicted
moms
and
babies
at
risk
seniors
and
at
a
school-based
health
center.
For
the
past
few
sessions
she
served
as
the
chair
of
the
Oregon
Senate
Health
and
Human
Services
Committee.
B
B
As
representative
Weaver
said,
my
experience
in
the
past
12
to
15
years
actually
has
been
working
with
a
lot
of
state
and
federal
policymakers,
particularly
on
Medicaid
policy
and
Medicaid
reform
and
I
think
that,
to
a
large
extent
we
sometimes
get
accused
in
the
Medicaid
world
of
purposely
making
things
complicated
and
I.
Don't
think
that's
so
much
true,
it
is
really
complicated.
B
A
lot
of
us
are
in
that
we
know
some
we're
trying
to
get
our
feet
underneath
us
and
really
move
some
things
forward,
but
we
even
have
some
beginners,
and
so
it
is
really
important
for
us
to
get
a
firm
understanding,
and
so
what
we're
going
to
do
today
is
kind
of
talk
to
you
about.
What's
the
vocabulary,
what's
the
activity
that's
going
on
in
innovations
across
the
country
and
Medicaid
and
then
really
I
hope
have
a
discussion
about
what
you
all
are
needing
and
thinking
about,
and
what
we
can
do
to
help.
B
You
think
that,
through,
as
representative
Weaver
said,
of
course,
the
program
is
continuing
to
grow
more
people
more
money,
but
I
think
one
of
the
things
that
we
don't
spend
as
much
time
talking
about
is
it's
also
really
becoming
more
and
more
complex
and
so
I
think.
One
of
the
things
that
we
really
need
to
focus
on
is
that
organizationally
is
becoming
more
complex.
B
The
people
who
are
enrolled
in
Medicaid,
where
have
many
more
and
very
and
quite
varied,
needs
in
terms
of
the
kinds
of
services
that
they
require,
and,
and
so
it's
just
it's
not
just
growing
in
numbers
and
in
dollars,
but
really
an
insert
of
what
the
scope
of
the
program
really
is.
But
also
as
these
as
this
complexity
grows.
We
have
a
lot
more
stakeholders
who
are
very
interested
in
the
program,
success
and
operation,
and
so
we're
going
to
talk
a
lot
about
not
just
the
innovations
that
are
happening.
B
But
what
this
who
the
stakeholders
are,
that
we
need
to
involve
so
in
response
to
the
growing
pressures
from
all
sides.
All
of
you
and
many
other
stakeholders
and
state
leadership
are
really
trying
to
look
for
ways
to
make
the
program
operate
more
effectively
and
more
efficiently,
and
a
lot
of
this
has
been
bucketed
into
a
very
large
category
of
activities
that
we
call
delivery
system
and
payment
reform.
B
So
what
we're
going
to
try
to
do
is
give
you
some
some
ideas
of
what
that
means,
because
it's
a
very
large
set
of
activities,
and
so
my
intention
here
to
start
us
office
to
give
us
some
some
vocabulary,
some
ideas
about
how
to
talk
about
this
issue
and
where
we
are
on
it.
One
of
the
most
frequent
phrases
out
there
right
now
in
Medicaid
reform
and
increasingly
in
Medicare
reform,
which
we
can
touch
on
more.
B
If
we
want
to
is
the
concept
of
value-based
purchasing-
and
this
is
a
very
simple
idea-
but
has
many
different
sort
of
ways
that
it
looks
so
it's
really
just
about
paying
for
outcomes
instead
of
paying
for
numbers
of
procedures,
and
so
that's
a
simple
concept
with
many
different
expressions.
So
some
of
the
things
that
we're
seeing
out
there
are
ideas
about
paying
for
performance
and
outcomes,
you're,
seeing
the
use
of
incentive
pools
where
people
are
pooling
dollars
and
then
you're
distributing
them
based
on
performance
in
some
way.
You're
seeing
some
concepts
called
shared
savings.
B
We're
simply,
if
we're
collectively,
seeing
some
improvements
in
cost
performance
of
the
program.
We're
going
to
share
those
between
the
state
and
with
our
providers
in
the
community,
and
so
that's
a
concept
that
you're
hearing
a
lot,
and
I
really
suggest
you
tune
in
to
the
value-based
purchasing
conversation.
B
B
You're,
seeing
things
like
health
homes,
accountable
care
organizations
and
other
types
of
arrangements
that
are
really
trying
to
bring
all
of
the
different
providers
for
different
aspects
of
Medicaid
under
one
operating
principle
and
I.
Think
that's
a
really
important
concept.
When
we're
thinking
about
a
fish
efficiency
of
the
program,
we're
going
to
be
more
efficient.
If
we're
working
together,
another
important
concept
of
Medicaid
innovation
is
a
simple
one.
Again
follow
the
money.
B
There
are
individuals
in
our
Medicaid
program
who
are
using
a
lot
of
services
and
a
lot
of
your
Medicaid
budgets
in
a
small
number
of
individuals,
and
so
it's
really
incredibly
important
to
think
about
how
you're,
how
you're,
focusing
and
targeting
your
interventions
on
some
of
those
individuals,
sometimes
they're
called
frequent
flyers
or
super
utilizers.
But
the
concept
is
really
the
one
that
you've
got.
B
And
how
are
we
doing
those
in
Medicaid
and
how
are
we
innovating
in
that
space
to
make
the
program
more
effective
and
then
I
think
you'll
hear
a
lot
of
examples
in
this,
in
our
conversation,
I'm
sure,
as
well
as
from
our
two
senators
here
about
community,
led
efforts
so
obviously
you're
working
at
the
state
level
and
working
on
state
policy
efforts
to
do
Medicaid
reform.
But
a
lot
of
emphasis
now
is
being
put
on.
B
So
that's
some
of
the
places
where
Medicaid
innovation
is
putting
some
emphasis
and
I
want
to
talk
for
just
a
minute
or
two
about
okay.
So
if
you've
picked
a
target
or
you've
picked
a
place
where
you
really
want
to
make
some
progress
in
your
Medicaid
reforms,
what
do
you
need
to
do
that
and
so
I'm
going
to
talk
a
little
bit
about?
Essentially
the
tools
for
reform
and
what's
what's
important?
B
Is
the
tools
are
the
same
kind
of
no
matter
what
area
you
want
to
work
on,
so
we'll
sort
of
talk
about
it
at
that
level
and
I
really
encourage
you
as
you're
listening
to
our
senators
present
their
their
stories
from
their
states.
Think
about
how
those
what
what
sort
of
tools
you
have
that
would
be
available
to
you
to
move
forward
on
these
initiatives.
B
So
it's
a
complex
area,
as
I
said
it
takes.
You
have
to
pull
a
lot
of
levers
to
make
reform,
and
one
of
the
the
most
important,
I
think,
is
really
the
issue
around
having
information
and
data
and
being
able
to
analyze
it
to
be
able
to
understand.
What's
happening
in
your
community
is
what's
happening
for
your
medicaid
enrollees,
and
so
one
of
the
biggest
tools
for
Medicaid
reform
is
really
data.
B
So,
as
a
as
a
public
program,
you
have
an
opportunity
to
leverage
how
your
dollars
are
used
and
what
you
get
for
your
dollars
and
so
looking
at
your
structures,
your
ability
to,
for
example,
competitively
contract
and
to
enforce
what
you
want
to
see
out
in
the
communities
through
your
contract
vehicles,
I
think,
is
a
really
important
place
and
then
how
do
you
oversee
that
contracts?
Once
you
have
a
contract
either
for
managed
care
or
for
an
accountable
care
organization?
B
How
do
you
make
sure
that
what
you
want
to
have
happen
is
happening
so
I
think
a
lot
of
the
accountability
structures
are
important
and
then,
as
always,
payment
payment
reform
is
increasingly
the
way
that
we
are
going
to
actualize.
What
we're
all
talking
about
and
that's
an
uncomfortable
conversation
right.
No
one
wants
to
talk
about
their
money,
they
want
to
just
do
it
and
they
promise
they'll.
Do
it
and,
let's
just
move
on,
we
don't
have
to
be.
B
So
a
lot
of
people
are
taking
a
community
level
approach
to
Medicaid
reform
and
one
that
I
think
you
all
can
consider
and
I
think
probably
the
most
important
aspect
of
any
of
these
is.
We
have
to
have
the
providers
on
our
side.
We
can't
do
these
things
without
a
committed
provider,
environment
and
so
I
think
that
that,
as
as
legislators
and
as
people
who
work
on
that
side,
I
think
that's
really
an
important
part.
B
Is
you
got
to
figure
out
how
to
get
your
providers
to
come
along
with
you
and
those
are
really
tools
that
you
can
apply
to
any
of
these
models
that
are
out
there
for
Medicaid
innovation,
the
data,
the
money,
the
contracting,
the
communities
and
the
provider
by
in
so
Samantha?
If
you
want
to
go
ahead
and
turn
to
our
next
question,
I
wanted
to
sort
of
put
up
our
our
polling
question
here.
To
talk
about.
B
B
So
what
were
what
we'd,
like
you
to
do
is
take
a
few
minutes
to
just
sort
of
tell
us
where
you
are
as
or
you,
regardless
of
whether
you're
a
legislator
or
just
in
the
community.
What's
your
opinion
about
the
it's
dropping
there
we
go.
That's
that's
closer!
So
what's
your
opinion
about
where
your
state
really
falls
on
this
spectrum?
Are
you
in
a
state
that
is
just
gung-ho
driving
towards
reform?
Are
you
in
a
state?
B
That's
going
really
don't
want
to
play,
but
I
think
we're
going
to
have
to
so
so
go
ahead
and
give
us
your
opinions
on
this
and
I
just
wanted
to
talk
for
a
minute
about
what
we're
going
to
try
to
do
so.
I
think,
to
a
large
extent,
when
you
look
across
there's
probably
some
of
the
kinds
of
innovations
that
I
mentioned
being
considered
or
implemented
in
your
state
right
now,
small
scale,
large
scale,
those
kinds
of
things
are
certainly
playing
out.
B
I
would
suggest
that
you
will
probably
need
a
number
of
different
innovations
over
the
next
few
years
to
actually
get
the
kinds
of
efficiency
and
effectiveness,
improvements
that
I
think
we're
all.
Looking
but
I
also
wanted
to
mention
and
you'll,
hear
this
I'm
sure
from
from
our
from
our
to
state
examples,
but
this
is
not
easy,
and
this
is
not
fast
and
so
I
think
one
of
the
most
important
parts
of
engaging
in
the
Medicaid
innovation
space
and
in
delivery
system
reform
is
you
got
to
sort
of
set
your
own
internal
expectations?
B
It's
going
to
take
more
time
than
you
can
possibly
imagine
it's
going
to
be
harder
and
probably
produce
less
than
you
would
like
it
to
particularly
on,
and
so
I
really
encourage
you
to
not
to
not
relinquish
your
efforts,
because
it
is
going
to
be
something
that
I
think
you
will
see.
Progress
is
being
made,
and
so,
if
we
all
stick
with
it,
I
think
that's
what
we're
going
to
be
able
to
find.
So
we
do
have
our
polling
results
are
in.
B
We
do
have
a
lot
of
states
that
are
in
the
early
or
just
early
stages
or
recently
launched
initiatives.
We
have
a
few
states
that
feeling
like
they
are
quite
advanced
and
are
really
moving
the
needle
quite
a
bit
or
doing
a
lot
of
activity
and
then
I
think
and
not
surprisingly,
about
a
quarter
of
you
are
thinking.
I,
don't
know
what
our
agenda
is
going
to
look
like
and
I
think
that's
that's
reflective
of
where
we
are
in
a
lot
of
different
spaces.
B
D
Can
you
all
hear
me
I
am
from
oregon,
I'm
a
state
senator
I've
been
chairing
the
Senate
Health
Care
Committee
since
2004,
and
that's
when
our
transformation
happened
and
believe
me
being
a
health
care
provider.
I
thought
that
I
would
know
a
whole
lot
about
Medicaid,
and
it
is
that
was
not
the
case
and
I
am
still
learning
and
it's
gurus
like
Kathleen.
That
can
help
us
keep
on
track.
D
We
have
made
a
number
of
changes
in
Oregon
and
for
a
variety
of
reasons,
but
we
knew
that
our
physical
health
and
our
behavioral
health,
our
mental
health,
dental
care,
Public
Health.
They
were
all
silos
and
they
were
all
costing
our
state
a
lot
of
money.
So
what
we
did
is
we
developed
what
we
call
the
coordinated
care
model
and
we
had
a
huge
process
where
the
governor
pulled
all
stakeholders
together,
I
mean
we
had.
Legislators
ensures
health
care
providers,
hospitals,
dental
alcohol
and
drugs,
physical
therapist
chiropractors.
Yes,.
D
Physicians,
consumers,
we
all
were
at
the
table
because
we
all
had
a
vision
of
how
we
wanted
health
care
to
be
delivered
and
provided
in
the
state
of
Oregon,
and
we
now
do
have
a
coordinated
care
model.
We
have
16
coordinated
our
organizations,
so
every
part
of
the
state
has
a
CCO,
a
coordinated
care
organization.
Now
we
have
more
than
a
million
Medicaid
members
that
are
signed
up
in
our
ccos
and
we
are
an
expansion,
Medicaid
expansion
state
which
added
about
400,000
oregonians.
D
D
They
have
all
agreed
to
work
together
in
their
local
communities
to
serve
people
who
receive
care
coverage
under
the
Oregon
Health
Plan,
which
we
call
Medicaid
our
oregon
health
plan.
What
are
its?
It's
working,
we're
still,
learning
changes
are
being
made,
but
Oregon
is
experiencing
improved
and
more
integrated
care
and
we
are
saving
money
with
a
focus
on
the
product.
Their
focus
is
on
primary
care
and
prevention
and
health
plans
are
using
the
care
model,
coordinated
care
models
to
better
manage
the
chronic
conditions
that
Kathleen
had
mentioned
that
use
up.
D
So
much
of
our
resources
and
they're
keeping
people
healthy
and
out
of
the
emergency
rooms.
Ccos
are
local.
They
are
governed
by
a
partnership
among
the
health
care
providers,
community
members
and
stakeholders
in
the
health
systems,
and
they
must
have
a
financial
responsibility
and
risk
contracts
are
set
up
with
each
CCO.
We
have
16
in
the
state
with
the
Oregon
Health
Authority,
so
contracts
are
set
up,
they
have
outcomes
and
I'll
get
to
that
a
little
bit
later.
D
They
have
one
budget,
they
are
paid
so
much
per
member
per
month
and
we
call
this
a
global
budget
and
they
can
use
that
money.
However,
they
feel
is
appropriate
and
there's
a
lot
of
flexible
spending
where
maybe
buying
an
air
conditioner
is
going
to
prevent
someone
from
keeping
on
going
into
the
emergency
room.
So
we
do
have
I
think
a
very
innovative
way
of
taking
care
of
our
patients.
We
have
had
runaway
costs
two
years
into
our
system
transformation.
D
Oregon
is
staying
within
the
budget
that
meets
its
commitment
to
the
Center
for
Medicare
and
Medicaid
Services
to
reduce
the
growth
in
spending
by
2
percentage
points
per
member
per
per
year,
so
it
was
5.4
percent.
The
the
growth
per
member
per
month
each
year,
we're
now
down
to
just
three
percent
per
member
per
month:
growth
%.
So
this
is
saved
the
federal
government
already
1.4
billion
dollars.
Well,
they
will
say
that
within
the
five
years
and
it's
on
track
to
save
6.5
billion
in
the
next
ten
years.
D
Okay.
So
what
do
these
ccos
have
to
be
held
accountable
for
its
in
their
contract
and
they
are
the
Oregon
Health
Authority
is
tracking
17
CCO
incentive,
metrics
and
16
additional
state
performance,
metrics
and
I'll
get
to
what
a
metrics
is
when
you're
using
quality
access
and
financial
metrics
together,
the
state
can
really
determine
which
CCO
it
is
a
effective
and
adequately
improving
care,
making
quality
of
care
accessible,
eliminating
health
disparities,
which
is
huge
and
controlling
costs
for
the
populations.
D
We
are
paying
ccos
for
quality
care,
better
health
outcomes,
we're
not
paying
just
for
more
services,
as
Kathleen
had
mentioned
before.
There
are
innovation,
payment
methods
and
episode
based
payments,
the
incentives
for
quality
outcomes,
that's
what
we
want,
not
volume-based
fees,
so
of
the
33
quality
and
access
metrics.
The
CCOs
are
receiving
incentive
payments
from
a
pool
for
making
targeted
improvements
in
the
system
and
meeting
at
least
17
of
the
benchmark,
metrics
that
that's
in
their
contract.
D
Now,
if
a
CCO
does
not
use
get
all
of
its
money
back,
that
money
goes
into
a
pool
and
it's
called
a
challenge
pool
where
the
funds
are
available
for
ccos
that
are
really
high,
achieving
and
key
metrics
and
believe
it
or
not.
When
you
provide
this
incentive
for
them,
they
are
trying
very
hard
to
meet
those
benchmarks.
This
is
the
third
year
of
oregon's
pay
for
performance
progress
and
we
still
are
taking
some
metrics
off
in
the
contract
and
adding
some
the
most
recent
one
is
sealants
dental
sealants.
D
They
decided
to
add,
because
you
know,
dental
care
is
still
even
though
we
have
it
in
our
model.
It
is
very
difficult
to
make
sure
that
we
have
good
outcomes
in
dental
care,
so
we
we
are
seeing
an
increased
rate
in
just
one
year
of
dental
sealants.
We
have
the
emergency
department.
Visits
have
decreased
by
23%
hospital
readmissions
have
decreased,
there's
an
twenty-nine
percent
for
short
term
complications
from
diabetes,
that
is,
it
has
decreased
like
COPD,
that's
chronic,
obstructive
pulmonary
disease
that
has
decreased
sixty-three
percent
congestive
heart
failure
has
decreased.
D
These
are
readmitted
twenty-nine
percent,
so
we
are
saving
money.
With
this
model.
We
now
have
a
metrics
on
the
percent
of
children
and
adolescents
that
must
get
a
primary
care
provider
that
is
happening.
We
have
now
increased.
Another
metrics
is
a
screening
for
depression,
again
inc.
It's
increasing
as
well
as
over.
Eighty
four
percent
of
our
Medicaid
population
is
in
a
primary
care
home.
That
is
an
incentive.
It's
up
to
the
CCOs,
to
make
sure
that
every
Medicaid
patient
is
in
a
primary
care
home
and
there
are
providers
that
are
providing
that.
D
Yes,
we
have
our
federally
qualified
health
centers,
which
are
a
part
of
this
system,
but
there
are
clinics
and
providers
that
are
are
also
being
considered.
A
primary
care
home
we've
increased
the
use
of
effective
contraceptives,
that's
another
metrics.
The
percent
of
women
ages,
15
to
50
are
now
using
and
effective
contraceptive
and
by
well,
it's
increased
nine
percent.
So,
as
you
can
see,
we
have
a
number
of
metrics.
D
D
We
are
developing
our
health
information
technology
services
are
going
to
be
launched
in
2017.
We
need
to
have
more
efficient
and
effective
care
coordination.
We
need
more
analytics
population
management.
You
know
this
is
all
stuff
that
I
don't
understand
as
a
provider
at
all.
She
does
but
I.
Don't
we
have
some
pilots
on
telehealth.
A
lot
of
our
state
is
rural,
and
so
we
worked
on
legislation
to
pass
telehealth
pilots
and
they
are
now
working
on
it
on
a
system
and
its.
If
it's
successful
in.
B
D
B
Thanks
senator
and
I
think
that's
it's
good
to
see
this
kind
of
excitement,
but
I
think
one
of
the
things
that
you
said
it's
so
important
is
that
it's
an
iterative
process,
and
so
we'll
talk
some
more
about
that
too.
I
think
another
thing
I
wanted
to
highlight
is
one
of
the
most
important
innovation
is
a
very
simple
one,
which
is
keeping
people
out
of
the
emergency
room.
We
know
that
that
is
not.
B
That
is
one
of
the
things
that
we
know
has
been
broken
about
our
system,
but
it
takes
communities,
intervening
and
I
think
that's
a
really
important
part
that
we
can
talk
about
some
more
in
our
session.
This
is
really
just
to
give
you
a
flavor
about.
What's
going
on
in
these
two
states
give
you
some
baseline
and
then
we're
going
to
come
back
and
talk
a
little
bit
more
about
some
of
the
lessons
that
they've
learned
but
senator
Watson.
You
want
to
go
ahead
and.
E
F
E
Let
me
do
a
product
placement
here.
The
NCSL
recently
produced
a
paper
on
improving
the
health
care
system.
Seven
state
strategies-
probably
everything
we
talked
about
here
today-
is
included
in
this
document.
So
I
would
encourage
you
to
going
to
be
motor
close
to
the
microphone.
Do
I
need
to
start
over?
Please
please
a
product
placement,
so,
if
you
haven't
received
this
in
the
mail
seek
one
out
today
and
read,
it
will
have
a
lot
of
the
information
that
we
will
probably
discuss
with.
You.
E
E
The
reality
of
it
is
it's
a
one-sided
deal
and
if
you
think,
you're
innovating
you're
lying
to
yourself,
you're,
not
the
feds
are
telling
you
what
they
will
or
will
not
allow
you
to
do
and
most
of
the
ideas
that
you're
creating
are
being
germinated
in
probably
Northern
Virginia
in
the
DC
area.
They're
coming
out
of
some
think
tank
and
they're
being
permeated
to
all
of
us
here
and
that's
well
and
good
and
they're
good
ideas,
but
the
reality
of
it
is
because
so
much
of
the
money
comes
from
the
federal
government.
E
They
actually
tell
us
what
we
do
or
we
don't
do
with
our
Medicaid
or
10
care
systems.
Now,
in
Tennessee
in
the
early
90s,
our
governor,
then
Ned
McWherter
had
a
brilliant
idea
that
we
would
be
a
state
in
a
leading
model
of
innovation
in
the
Medicaid
system.
So
we
went
to
our
friends
at
the
federal
government,
who
often
aren't
so
friendly
to
us,
and
we
said,
hey
we'd
like
to
create
our
own
little
system
here,
using
a
managed
care
model.
Well
at
the
time
is
fuel.
E
Remember
those
of
you
that
were
around
Hillary
Clinton
was
pushing
for
a
pretty
strong
health
care
program.
Clinton's
were
interested
in
that
kind
of
innovation,
which
is
either
neither
good
nor
bad.
So
Tennessee
became
one
of
the
first
waiver
states
and
we
became
all
of
our
ten
care
or
all
of
our
Medicaid
patients
were
put
into
managed
care
programs,
most
of
which
had
never
operated
any
kind
of
managed
care
program
in
their
insurance
history,
and
it
became
a
huge
debacle
and
over
about
a
15
year
period
of
time.
E
It
went
from
consuming
about
fifteen
percent
of
our
state's
budget
up
and
started
breaking
into
the
30,
the
35
percent
of
our
state
budgets.
So
in
the
early
2000s,
the
new
governor
governor
Bredesen
looked
at
met
the
rising
Medicaid
course.
The
first
thing
he
did
was
he
hired
some
consultants
to
come
in
and
look
at
our
Medicaid
system
and
they
came
in
and
looked
at
the
system
and
said
you're
spending
too
much
on
Medicaid
or
ten
care,
even
though
it's
spud
managed
care
and
it's
supposed
to
help.
E
Control
costs
only
been
two
states
in
the
history
of
Medicaid.
Since
nineteen,
since
the
1960s
that
have
actually
radically
changed,
it
main
is
made
from
Maine
here,
yeah
there's
guy
good
Maine
Maine
made
some
significant
modifications
to
their
Medicaid
system
and
Tennessee.
Where
I
was
a
member
of
the
house
at
the
time,
and
we
cut
our
TennCare
rolls
reducing
benefits
to
the
tune
of
eliminating
a
hundred
and
eighty
thousand
people.
Now
those
of
you
out
in
the
audience
who
think
it's
easy
to
make
those
kind
of
cuts.
E
Let
me
invite
you
to
come
and
visit
Tennessee
and
see
how
people
feel
about
that.
Those
of
you
that
have
have
expanded
your
Medicaid
systems.
I,
certainly
you
know
that's
obvious
choice.
Each
state
has,
but
when
your
calls
start
to
run
away
with
it,
you're
left
with
a
limited
number
of
options
or
how
you're
going
to
control
those
costs,
and
so
in
about
2005-2006
we
cut
our
Medicaid
rolls
by
about
180,000
people.
E
Creating
a
financially
stable
tin
care
system
still
requires
us
to
go
to
the
federal
government
of
fact,
we're
back
this
year,
asking
the
federal
government
for
permission
to
continue
our
partnership
with
them
in
our
ten
care
program.
Let
me
tell
you
how
ours
operates
and
then
hopefully
we'll
get
into
some
good
conversation
and
discussion
here,
because
you
don't
want
to
hear
me
talking.
I
get
to
ranting,
sometimes
and
I've
already
started
I
apologize.
E
Tennessee
has
actually
done
a
lot
of
innovative
within
the
confines
that
the
feds
will.
Let
us
do
a
lot
of
innovative
thinking
around
Medicaid
or
TennCare,
mainly
because
we
have
a
pretty
unhealthy
population.
I
mean
look,
we're
not
a
wealthy
state,
we're
not
in
Oregon
Oregon's
per
capita
incomes
a
lot
higher
than
Tennessee's
their
level
of
standard
level
of
education
is
higher
than
Tennessee's.
We
used
to
be
up
we're
surrounded
by
some
tobacco
states
like
North,
Carolina
and
Virginia.
E
So
obviously
over
history,
we've
developed
some
health
disparities
that
create
financial
problems
for
us
when
you
have
a
Medicaid
program,
but
even
within
that
mallu
we
have
been
able
to
reduce
the
growth
in
Medicaid
or
costs
at
about
half
of
what
all
the
other
states
do.
So
if
your
state
grew
at
about
six
percent
this
year,
which
is
about
the
most
states,
did
ours
grew
at
three
percent.
The
way
we've
done,
that
is,
we've
done
a
lot
of
different
things.
Around
benefits.
We've
got
some
really
good
partners.
E
Or
I
can
get
incentivized
by
the
savings
for
that,
then
I'm
going
to
work
really
hard
to
make
that
war
happen.
So
what
happens?
Is
let's
take
a
common
one?
Usually
these
work
around
standardized
procedures.
The
most
common
when
I'm
familiar
with
in
your
state
Medicaid
director,
would
be
familiar
with
its
total
joint
replacement,
fairly
standardized
approach.
E
It's
pretty
simple
procedure
if
you're
trained
as
an
orthopedic
surgeon,
if
you're
an
insurance
salesman,
try
to
do
what
I
wouldn't
recommend
it
to
you
nor
to
the
patient,
but
if
you're
an
orthopedic
surgeon
in
the
way
that
that
a
total
joint
replacement
works.
It's
it's
a
three-day
experience
for
the
patient
for
the
most
part.
In
that
episode
care,
you
would
make
your
orthopedic
surgeon,
the
quarterback
of
the
team,
now
the
more
and
it's
almost
like
a
capitated
system.
E
So
I'm
going
to
make
the
math
simple,
because
I
know
it
got
some
folks
from
alabama
here.
So
I
thought
I'd
wake
you
up
eventually.
I'd
say
I
thought
I
was
at
the
funeral
home
directors
meeting
here,
its
Medicaid,
so
I'm
going
to
pay
you're
the
quarterback
of
the
episode
of
care,
I'm
going
to
pay
you
a
hundred
dollars
to
take
care
of
my
patient
logan
over
here
who
actually
heat
staffs.
Our
health
committee
in
the
senate
and
you've
got
a
hundred
dollars
to
spend
on
all
the
services
nest
to
get
that
total
joint
done.
E
That
includes
the
pavement
of
the
the
implant
that
includes
the
hospitalization.
That
includes
all
the
other
characters
that
want
to
participate
in
the
care
of
this
patient.
Your
job
is
to
do
it
at
ninety
dollars,
rather
than
a
hundred
dollars,
because
if
you
save
ten
dollars
I
as
the
pay
are
going
to
provide
you
with
an
incentive
for
having
saved
those
ten
dollars
at
the
end
of
the
year,
I'm
going
to
add
up
all
the
total
joint
patients
you
saw
and
I'm
going
to
measure
you
against
all
the
other
people.
E
Who've
done
total
joints
in
the
area
and
I'm
going
to
decide
based
on
those
metrics,
whether
you
get
incentivized
or
guess
what
you
owe
me
money,
because
you
didn't
keep
to
the
plan
of
keeping
costs
down
that
uses
capitalistic
thinking
or
the
profit
motive
in
order
to
try
and
get
help
drive
costs
down.
That's
one
methodology
that
we're
using
now
here's
the
challenge.
E
You
need
to
have
a
relationship
with
those
folks
as
well,
because
they
are
doing
a
lot
of
data
mining
to
help
them
understand
what
what
helps
what
drives
health
care
and
what
drives
patients
to
or
from
healthcare
and
here's
the
end
of
the
story
and
I
know
you
want
to
move
along.
The
challenge
that
we
have
is
the
child,
like
the
challenge
that
we
have
in
education,
we
have
a
dysfunctional
system
that
we're
now
trying
to
superimpose
other
kind
of
systems
on
top
of
to
try
to
make
it
work
better.
E
All
the
things
that
we're
talking
about
here
today.
All
of
these
things
that
are
printed
in
here
are
creative
ways
of
trying
to
work
around
a
system
that
does
not
use
normal
economic
principles,
because
in
all
this
conversation,
the
one
person
who
never
gets
included
in
the
conversation
is
the
consumer,
because
the
hospital
or
the
doctor
of
the
physical
therapist
of
the
nurse
or
whoever
the
character
might
be.
Their
conversation
is
not
between
themselves
and
their
patient
about
how
we
pay
their
conversation
is
between
them
and
the
payor.
E
Who
is
a
broker
for
the
patient,
and
now
we
have
to
try
and
reinsert
into
the
system
market
principles
that
normally
operate
in
the
market
when
there
is
a
relationship
between
the
consumer
and
the
provider,
and
that
doesn't
exist
in
health
care.
That's
neither
good
nor
bad.
It's
just
how
it
is,
and
so,
like
education,
where
we
know
we
have
some
faults
in
the
foundation
of
how
the
system
was
built.
E
We
know
for
darn
sure
that
in
health
care
we
have
faults
in
the
foundation
of
how
the
system
was
built,
and
so
now
we're
trying
to
figure
out.
How
do
we
empower
we
put
into
place
some
market
factors
that
will
help
naturally
drive
down
the
cost
of
healthcare?
Healthcare
like
most
products
will
never
go
down.
The
cost
will
never
go
down.
E
What
you
will
see
is,
or
what
we're
trying
to
do
is
control,
how
much
and
how
fast
the
growth
of
the
cost
is,
and
as
a
technology
advances,
it
will
make
the
per
unit
of
service
less
expensive
and
for
those
of
you
in
the
manufacturing
industry.
You'll
know
what
that
means.
But
you
know
television
today
that
you
pay
five
hundred
dollars
for
that
same
TV
would
be
fifteen
thousand
dollars
in
1960,
because
technology
just
wasn't
there.
So
the
outlook
for
healthcare
is
incredibly
positive.
E
I
don't
mean
to
sound
negative,
but
it
tends
to
get
people
aroused
when
you're
at
these
kind
of
things,
but
the
reality
of
it
is
states
need
to
stand
up
and
if
we're
going
to
be
innovative,
we
need
to
challenge
or
partner
around
Medicaid
and
the
federal
level
to
allow
us
to
innovate.
One
of
those
ways
would
be
to
allow
states
block
grants
to
where
they
could
do
what
they
want
to
do
with
the
money
that
they've
sent
in
the
money.
That's
come
back
and
I'll
yield,
so
we
can
have
conversation
Thank.
B
B
Those
are
your
three
cost-saving
measures
and
each
one
of
these
states
has
been
through
all
of
those
and
they're
still
back
here,
because
really
the
solution
for
us
all
is
to
just
flip
the
script.
It's
to
do
something
different
and
I.
Think
your
point
Center
Watson
about
we're,
going
to
get
better
at
innovating,
we're
going
to
get
better
at
reform
and
it's
going
to
come
cheaper
and
it's
going
to
come
easier,
the
more
that
we
do.
It
and
I
really
think
that's
where
the
point
of
where
we
are
right
now
is.
B
It
is
really
hard
to
do
some
of
these
reforms,
but
it's
getting
easier
as
we
all
come
at
it
and
as
we
learn
from
our
both
our
mistakes
and
from
our
success
is
to
really
learn
how
to
do
it.
I
think
it's
going
to
get
easier
and
easier
as
we
go
along
and
we
have
to
do
it
because
we're
just
kind
of
stuck
in
where
we
are
and
we've
used
a
lot
of
the
tools
we
have
and
we
have
to
come
up
with
new
tools.
So
we're
gonna
I'm
going
to
ask
you
a
question
here.
B
We
have
a
polling
question
just
really
quickly
and
I.
Think
both
of
our
folks
sort
of
talked
about
about
this
I.
Think
one
of
the
pieces
of
this
question
is
is,
who
do
you
think
is
the
most
important
for
you
to
engage
in
your
and
your
Medicaid
reform
process,
but
I'll
sort
of
asked
this
question?
Who
do
you
not
have
on
board,
because
this
room
is
pretty
full?
B
What
what
would
you
say
of
all
of
the
things
that
you
have
experienced
in
in
your
efforts
in
Tennessee
is
the
one
that
you
want
to
make
sure
that
they
leave
this
room
understanding?
What's
your
big
lesson
learned
that
you
want
to
make
sure
folks
are
to
come
to
on
this
I
know
I
sort
of
sprung
that
on
no.
E
Whatever
innovative
ideas
you
have
in
your
laboratory
of
democracy
back
home
in
your
state
has
got
to
be
packaged
in
such
a
way
that
you
can
get
your
partner
at
the
federal
level.
To
agree
to
I
mean
that's
just
the
truth:
I
mean
I,
you
know,
states
have
have,
and
it
comes
down
to
the
point
that
the
federal
level
that
help
believe
the
states
will
really
utilize
the
money
to
the
degree
that
the
the
feds
want
them
to
and
quite
frankly,
administrations
have
made
that
statement
so
I
think
the
big
out.
E
And
if
you
want
to
understand
it,
that's
new,
that's
how
you
that's
whom
it
you
need
to
speak
with
now
and,
secondly,
that
there
is
no
one
size
that
fits
all.
Despite
what
national
governments
would
want
us
to
believe
what
works
in
Oregon
is
not
going
to
work
in
Tennessee,
because
people
were
going
to
different
are
different
than
the
people
of
Tennessee
I
assure
you.
The
people
of
Oregon
are
different
than
the
people
of
Tennessee.
F
E
I
mean
seriously
I
mean
each
state
has
to
craft
a
program,
and
that's
that
and
I
guess
you
can
sense.
My
frustration,
that's
my
frustration
is
I.
Don't
care
what
they
do.
An
organ
elects
people
to
make
their
decisions
if
they
won't
expand.
Medicaid,
that's
fine!
If
they
want
to
just
give
healthcare
away
in
Oregon.
That's
fine,
that's
organs!
E
Choice,
I,
want
the
liberty
and
the
independence
in
Tennessee
to
make
those
same
kind
of
decisions
without
somebody
else
telling
us
how
we
need
to
do
it
and
I
suspect
many
of
my
friends
in
Alabama
and
Georgia
and
North
Carolina
those
around
the
eight
states
that
surround
our
state
kind
of
feel.
The
same
way.
It's
easy
to
talk
about
innovation.
It's
tough
to
implement
infant
innovation
when
you
have
a
partner
who's,
making
it
hard
on.
You
I
think.
B
Your
your
point
about
understanding
your
own
Medicaid
program,
I
think,
is
really
create
key
to
I
mean,
and
I
think
that
is
a
critical
component,
but
we
can't
forget
that
there
there
is
a
partner
in
in
our
current
situation
in
and
it
is
hard
it's
a
hard
relationship,
a
lot
of
the
time,
and
especially
when
it's
about
innovation,
and
so
I
think
that
is
something
to
be
watching.
Certainly
there's
the
changes
that
are
coming
at
the
federal
level
and
another
thing
to
be
watching.
B
B
Think
that's
one
of
the
most
telling
pieces
is,
if
you
have
your
stakeholders
on
your
side,
it's
a
lot
harder
for
the
federal
government
to
ignore
your
request
and
I
think
that
one
of
the
things
we've
seen
and
I've
been
in
Washington
for
I
won't
even
tell
you
how
long,
because
it's
not
worth
mentioning
but
too
long
and
that's
true
of
anybody.
Who's
been
there
for
more
than
a
couple
of
days,
but
but
but
but
one
of
the
things
I
think
is
so
important.
B
Is
that
if
you
come
with
a
good
idea,
the
first
thing
they're
gonna
do
is
call
all
your
other
folks
find
out
what
they
think
and
if
you
come
together
and
come
with
the
idea,
it's
much
more
likely
you're
going
to
get
somewhere.
So
just
something
to
be
thinking
about
Senator,
Morton
Sanderson.
Anything
you
wanted
to
share
I.
D
Think
every
state
needs
to
look
at
their
system
and
figure
out
how
they
are
able
to
reduce
costs.
When
you
look
at
the
last
50
years,
our
wages
have
gone
up.
Sixteen
percent,
but
health
care
costs
have
gone
up.
Eight
hundred
and
eighteen
percent
there's
a
huge
difference,
and
if
we
don't
get
our
costs
under
control,
which
we
are
trying
to
do
in
Oregon,
our
people
aren't
aren't
going
to
be
able
to
get.
D
There
will
be
less
and
less
people
getting
either
fewer
services
are
cutting
enough
people
so
that
they
don't
get
any
services
at
all.
We
do
so
I
think
that's
my
ki
KI
issued
for
you
to
take
a
look
at
and
get
everybody
at
the
table.
I
think
it
works
so
well.
We
we
met
to
try
to
come
up
with
our
model
model.
D
Every
the
governor
called
us
in
every
Wednesday
night
from
six
to
nine,
and
there
were
about
70
of
us
very
well
coordinated
and
it
worked
like
a
machine,
but
everyone
had
a
chance
to
give
its
input.
But
again
we
need
to
look
at
without
decreasing
quality
care
and
making
sure
that
people
can
get
care.
Looking
at
how
to
reduce
costs
well,.
E
And
and
that's
reducing
costs
obviously
is
a
huge
issue,
because
if
you
look
at
your
who
needs
to
be
most
engaged,
you've
got.
Sixty-Five
percent
of
those
folks
benefit
from
the
benefits
that
are
usually
provided
in
your
Medicaid
or
in
our
case
ten
care
program.
So
a
hard
part
about
the
negotiations.
B
So
we're
going
to
turn
to
the
audience
for
some
questions,
so
I
want
you
to
go
ahead
and
start
thinking
about
what
those
are,
but
I
think
before
we
do.
That
I
wanted
to
ask
one
more
polling
question,
because
I
think
this
really
gets
to
your
point:
Center
Mona's,
a
nation
about
about
the
issue
of
the
the
money
and
yours
as
well,
senator
because
I
think
this
is
the
issue
of
this.
B
Is
this
is
going
to
affect
people,
no
matter
how
we
think
about
it,
and
it
is
going
to
affect
both
on
the
on
sort
of
the
patient
side
in
terms
of
what
services
they
are.
They
have
access
to
as
well
as
what
providers
are
paid.
I
love
this
history,
so
this
is
really
fun.
Real-Time
polling,
I,
don't
know.
B
Is
there
a
particular
place
that
you
think
your
biggest
I'll
say
bang
for
the
buck,
although
that's
not
quite
where
I'm
going,
but
really,
where
you
think
you're,
settling
in
and
and
really
remarkable
and
not
surprising.
To
a
large
extent,
though,
is
a
lot
of
you
see
the
behavioral
health
connection.
I
think
this
is
one
of
our
our
biggest
challenges
and
I
wanted
to
get
back
to
something
that
you
said
senator
Watson
about
lord.
B
That's
always
been
something
out
there
and
suddenly
this
is
more
and
more
part
of
their
purview
and
likewise
with
Medicare.
You
know
when
we
Medicare
is
always
sort
of
this
big
behemoth
in
the
provider
community
that
we
have
to
kind
of
work
around
on
a
state
by
state
level,
and
yet
there
they've
just
started
to
talk
about
value-based
purchasing.
You
guys
have
been
talking
about
it
for
a
decade.
You
know
it's.
C
E
And
took
up
to
the
Pope
the
screen
instead,
I
guess
it.
We
should
have
said
when
I
was
talking
about
those
who
may
be
new
to
Medicaid,
got
to
remember
about
you'll,
know
the
exact
number,
but
thirty-five
forty
percent
of
Medicaid
dollars
go
to
long-term
care.
So
you
out
up
60,
you
know
you're
only
really
spending
less,
just
simple
math
for
our
friends
from
Mississippi
anybody
for
Mississippi.
E
Here
there
you
go,
you
know
so
every
dollar
you
spend
you
know
you're
only
spending,
60
cents
of
that
dollar,
on
actual
health
care,
the
others
on
long-term
care,
and
when
you
look
at
a
slide
like
that,
you
get
them.
I
get
the
impression
that
people
don't
or
people
tend
to
negate
the
long-term
care
aspect
of
Medicaid
systems,
which
is
actually
you
know
nearly
half
of
it.
That's.
B
E
B
E
E
I
y'all
have
done
a
great
job
in
your
long
term
care
of
community-based
services.
That's
another
aspect
of
your
state!
Isn't
looking
at
it!
I
guaranteed
your
Medicaid
director
is
looking
at
it
on
how
you
can
in
essence,
deinstitutionalized
our
long-term
care
services
and
provide
more
in
home
in
care
services.
Remember
40
cents
out
of
every
Medicaid
dollars
going
towards
long
terms
care.
So
don't
spend
all
your
time
talking
about
hospitals
and
doctors
and
nurses.
E
D
Do
have
a
program
called
Project
independence
and
we
have
we
have
fewer
residents
in
nursing
home
care
per
capita
than
any
than
one
most
of
other
states
in
the
in
the
nation,
and
we
do
find
that
being
able
to
keep
our
seniors
in
community-based
settings
or
in
their
own
home
rather
than
a
nursing.
Home
decreases
costs
significantly.
And
so
we
do
put
a
lot
of
effort
into
whether
a
person
needs
a
nurse
to
just
manage
the
meds
once
a
week
or
a
caretaker
to
come
in
just
once
a
day.
E
And
be
sure
and
engage
your
nursing
home
community
or
your
long-term
care
community,
because
if
you
were
like
Tennessee,
which
was
very
institutionally
based,
you
know
they
weren't
particularly
happy
when
we
decided
to
go
to
more
home
and
community-based
services,
keep
people
at
home.
But
they
have
been
helpful
in
building
the
infrastructure
in
order
to
do
that,
because
you
just
can't
walk
in
one
day
with
an
institutionalized
based
system
and
walk
out
the
next
day
with
one
that's
community-based,
because
you
don't
have
the
infrastructure
to
provide
the
services.
E
So
while
you
may
have
a
great
idea,
you
have
no
way
of
implementing
it.
So
I
would
encourage,
if
there's
any
folks
from
the
from
the
nursing,
home
or
lawn
care
industry.
Here
you
know,
engage
those
people
as
well,
because
they
really
have
a
lot
of
to
add
a
lot
of
value.
To
add
to
the
conversation,
but.
D
We
in
oregon
we're
sort
of
forced
to
be
able
to
have
to
go
to
a
community
based
system,
a
home
based
system,
because
the
reimbursement
rates
are
much
higher
for
nursing
home
care
in
on
the
East
Coast
than
it
is
on
the
west
coast.
So
at
least
in
Oregon
we
had.
We
had
find
out
a
different
way
to
be
able
to
take
care
of
our
seniors.
B
B
G
D
H
I'm
Keith
Frederick
from
mizoram
a
state
rep,
an
orthopedic
surgeon,
I,
particularly
involved,
or
appreciated,
senator
entres
comments
about
the
tolls
right,
but
you
made
a
point
senator
about
the
patient,
really
sort
of
being
left
out
of
the
equation
right
and
also
the
sort
of
the
disrupted
relationship
between
the
provider
of
services
and
the
consumer
of
services
from
the
typical
arrangement
in
in
society.
Right.
You
know,
with
the
value-based
emphasis
on
compensation
now.
Is
there
a
role
for
increasing
or
sort
of
empowering
the
patient?
H
The
last
few
years
I've
carried
bill
amazura
that
established
health
savings
accounts
as
a
mechanism
of
giving
the
patient
some
skin
in
the
game.
Didn't
get
much
traction,
but
this
year
aLEC
has
a
model
piece
of
legislation.
They
don't
call
them.
Hsa
is
a
column.
Medical
savings
accounts,
but
I
think
that's
the
way.
It's
it's
rach
really
shared
savings,
but
it's
not
shared
savings
with
the
providers.
It's
shared
savings
with
the
patient,
and
then
the
patient
has
motivation
and
skin
in
the
game
to
not
go
down
the
road
of
multiple
MRI
scans.
H
If
they
had
one
last
week,
they
don't
want
to
just
have
another
one
done
the
way
it
is
now.
Somebody
comes
in
the
office
late
on
MRI
scan
done
or
a
CT
scan.
Let's
say
the
ER
doctors
taking
care
of
them
for
flank
pain.
They
think
maybe
they
have
a
kidney
stone.
Well,
I
just
had
a
test
like
that
three
days
ago.
What's
three
o'clock
in
the
morning
your
age,
your
EHR,
doesn't
allow
you
to
access
the
scan.
E
Let
me
give
you
a
name
contact
senator
mark
Greene
in
Tennessee.
He's
got
an
innovative
idea.
The
feds
are
never
going
to
accept
it,
but
he's
got
an
innovative
idea.
That
does
that,
basically,
it's
a
little
bit
different
than
the
model
that
you've
got.
I've
got
senator
Becky
Massie
down
here
from
Tennessee
as
well.
E
E
That's
one
way
of
doing
now.
Of
course,
the
problem
is
is
that
humans
are
capitalistic
beasts
right
and
since
people
figure,
if
they
show
up
at
the
hospital,
they
got
to
take
care
of
me
whether
I
can
pay
for
it
or
not.
There's
some
incentive.
There
are
some
disincentives
that
will
make
people
not
follow
through
with
their
care.
E
You
know
not
have
their
regular
scheduled
appointments,
so
he
puts
into
some
parameters
for
that
to
ensure
that
if
you're
going
to
get
the
incentives
kind
of
like
leasing
a
car,
you
know
you
got
to
do
these
certain
things.
If
you're
going
to
lease
the
car
and
then
at
the
end
you
give
the
car
back,
you
don't
anything
on
it.
If
you
don't
do
those
things
you
can
owe
something
on
it.
So
it's
kind
of
innovative
thought
in
a
way.
Why
idea
I
appreciate
you
being
here,
I
appreciate
your
service
particular
is
North
peace.
E
B
B
I
think
that
you're
absolutely
right,
I'm
not
sure
how
far
we
get
fo
government,
particularly
around
any
sort
of
emergency
or
other
types
of
services,
but
certainly
some
states
have
floated
the
idea
of
penalties
for
using
the
emergency
room
and,
if
you
don't
need
to
so
those
have
been
floated
out
there,
they
have
not
yet
been
successful,
but
I
do
think
there
are
a
lot
of
more
on
the
incentive
side.
I
think
your
point
about
shared
savings
is
an
interesting
one.
I
Level,
hi
I'm,
Jerry,
Miller,
representative
Kentucky
and
just
going
off
of
the
same
theme
as
my
predecessor
from
Missouri
I,
actually
voted
aeon.
This
because
I
thought
I
think
it
is
the
the
key
is
either
incenting
or
punishing
not
punishing,
but
at
least
cope
setting
a
copay
or
a
reward
system
and
I
just
wanted
to
know.
If
any
of
you
all
had
tried
co-pays
and
what
you
thought
about
the
copay
idea,
as
opposed
to
the
incentive
and
Bo.
Thank
you
for
not
picking
on
Kentucky
well,.
I
D
E
D
Gotta
have
some
skin
in
the
game.
No
I
at
least
the
beginning,
satisfaction
surveys
of
our
our
Medicaid
population
that
are
a
part
of
a
CCO
and
that's
where
insurers
aren't
involved.
This
is
a
CCO,
that's
being
given
the
money,
and
then
they
figure
out
how
to
deliver
the
services.
So
far,
the
satisfaction
rates
have
been
pretty
positive.
Again,
it's
only
two
years
of
dad
worth
of
data,
so
give
us
five
years
well,.
E
I
E
Yeah
well,
I
was
just
going
to
say
the
satisfaction
rates
for
our
10
care
system
are
up
in
the
middle.
What
senator
Massey
middle
90s
upper
90s
I
mean
our
patients
are
very
satisfied
with
it
as
long
as
they
get
the
benefits
that
they
either
are
or
are
not
paying.
For
I
mean
patients
are
satisfied
sky,
like
your
wares,
more
orthopedic
guy
he's
familiar
with
the
Joint
Commission
on
the
accreditation
of
hospital
patients
gives
you
a
high
rating
if
you
give
them
their
pain
medication
when
they
leave
the
hospital.
E
Of
course,
they
do
I
mean
you
give
them
what
you
give
if
I
give
you
what
you
want
of
course,
you're
going
to
give
me
a
high
satisfaction
Randy.
The
challenge
is:
how
do
we
control
the
cost,
because,
if
you're
a
state
like
Tennessee,
we've
got
a
34
billion
dollar
budget,
you
cannot
allow
the
more
that
Medicaid
grows
in
our
state
budgets,
the
more
it
crowds
out
infrastructure.
It
crowds
out
education,
it
crowds
out
any
other
great
ideas.
You
might
have
what.
A
B
J
B
So,
but
we
don't
but
directly
to
the
provider,
we
haven't
had
great
success
with
either
all
the
time,
so
I
think
the
idea
of
making
communities
more
accountable
is
kind
of
an
interim
step.
It's
saying,
okay!
Well,
if
you
guys
can
get
more
of
the
preventive
services
use.
You
know
those
kinds
of
things,
so
it's
not
the
perfect
solution
and
it's
not
the
consumer
engagement
model
that
you're
talking
about
in
Tennessee,
but
it
is
a
half
step
that
I
think
some
people
are
considering
go
ahead.
Thank.
F
You
I'm
senator
mary
kay
peril
from
Montana
and
I
have
two
questions
for
Senator
Anderson.
One
is
up
with
your
accountable
care
organization.
I
heard
you
talk
about
a
lot
of
important
pieces
of
the
whole
health
care
system,
but
I
didn't
hear
disabilities
I'm
wondering
if
it
includes
disabilities
I
don't
mean
mental
health
I
mean
like
developmental
disabilities
or
physical
disabilities,
and
if
not,
why
and
then
to
do
you
send
explanation
of
benefits
out
to
your
Medicaid
members?
Does
your
state
do
that?
That's.
D
A
good
question:
I'm,
not
I,
I,
don't
know
the
answer
to
the
last
question.
I
do
not
know,
but
a
lot
of
our
disabilities
are
dual
eligibles
and
I'm.
Not
some
do
are
in
a
CCO,
but
I
I
know
that
a
number
of
them
we
have
about
a
hundred
and
fourteen
thousand
people
that
are
not
in
a
CCO
and
I
think
some
of
them
may
be.
Our
dual
eligibles
did.
B
F
Don't
have
that
in
Montana
and
I've
tried
to
pass
a
bill
because
I
think
if
you're
going
to
get
at
responsibility
and
accountability,
people
who
have
Medicaid
need
to
be
treated
the
same
as
people
have
private
insurance
and
get
an
explanation
of
benefits
and
also
my
fiscal
note
showed
that
it
reduced
fraud,
because
a
person
who
received
an
explanation
of
benefits
could
call
and
say
I,
never
received
this
service.
So
I
don't
understand
you.
E
D
F
K
If
you
do
have
a
disability
and
you
can
work
as
soon
as
you
start
working,
you
lose
your
health
care
after
a
while
I'm.
So
have
you
done
anything
that
looks
at
encouraging
people
to
go
back
to
work?
You
know.
We
know
these
folks
until
they
start
working
or
volunteering
they're
not
going
to
feel
better
about
themselves
and
if
they
don't
get
those
skills
they're.
Never
going
to
work
themselves
out
of
that
system,
and
it's
just
going
to
be
generational
and
I
know
the
feds
make
it
difficult.
K
We
put
in
our
legislation,
referrals
to
our
department
of
labor
or
education
services,
but
I
think
that's
the
barrier.
I
mean
our
goal
should
be
getting
people
off
of
Medicaid
that
are
able
to
get
off
of
it
and
a
better
level
of
life.
But
it
seems
that
the
system
just
wants
to
keep
people
trapped
at
that
lower
level
and.
D
You're
you're
right
on
on
that
and
there's
a
lot
of
work
to
be
done
on
that.
I
know
that
when
they
transfer
from
Medicaid
into
the
exchange-
and
we
have
a
very
viable
exchange
in
Oregon
there,
they
do
get
subsidies
depending
on
their
income
in
pain
for
their
health
insurance
and
it
comes
from
the
feds
and
so
that
that
helps
helps
them
be
able
to
keep
the
same
services
that
they
have.
But
we
still
the
deductibles
when
they
go
into
the
exchange.
They'll
choose
a
bronze
plan
and
deductibles
or
5,000.
E
E
E
B
Folks
have
gone
in
terms
of
the
federal
Google's
being
able
to
refer.
People
for
work
supports
is
now
part
in
some
Medicaid
sort
of
coaching
in
that
way
as
part
of
the
enrollment
process
and
other
parts,
so
it
is
out
there.
There
are
also
some
programs
for
people
who
have
disabilities
so
that
they
can
stay
on
Medicaid,
because
Medicaid
Services
are
continuing
and
are
much
richer
than
those
and
in
private
plans
for
people
with
disabilities.
B
So
there
are
work,
supports
that
you
can
use
and
Medicaid
and
keep
your
Medicaid
Services,
but
you
have
to
be
on
the
disability
phase.
You
can't
be
just
a
general
Medicaid
enrollees,
so
I,
don't
I
think
this
is
probably
one
of
the
most
critical
areas
we
still
have
to
figure
out
and
I.
Think
the
other.
What
about
yours?
Your
comments
under
Anderson
I
think
there's
the
potential
for
people
to
be
in
a
really
difficult
turn
situation
between
Medicaid
and
exchange
coverage.
B
F
K
B
C
Right
think
young
representative,
Kelly
McCarthy
from
the
great
state
of
Montana
and
and
senator
Watson
I,
want
to
commend
you
because
the
the
most
important
thing
with
finding
a
solution
is
being
able
to
frame
the
problem
and
you've
done
that
very
well.
So
thank
you
for
that.
I
think
this
is
probably
more
for
Senator
Anderson
or
almost
anybody
in
the
room.
But
in
the
last
six
months
most
of
my
work
in
the
healthcare
arena
has
been
with
that
super
utilizar
population
that
you
had
mentioned.
You
know
these
are.
C
These
are
two
to
five
percent
that
cost
the
twenty
to
thirty
percent,
and
so
what
we're
looking
at
is
is
you
know
addressing
the
social
determinants
that
these
folks
have
that
are
leading
to
poor
health
outcomes
and
so
senator
Anderson?
You
mentioned
something
about
your
ccos
and
you
know
somebody
bought
an
air,
conditioner
and
stuff
like
that
and
I'm
curious.
Have
you
found
a
solution
that
will
allow
you
know
a
housing
as
healthcare
type
of
solution?
C
D
Is
a
huge
issue
and
we
are
now
looking
at
determinants
to
see
how
that
can
fit
into
our
CCO,
because
we
do
have
a
big
big
homeless
population
as
well
as
affordable
housing.
I
mean
but
I,
don't
know
if
anyone
from
California
but
the
Californians
are
coming
up
to
Oregon
and
buying,
are
our
apartments
and
then
Vic
tanar
our
residents
and
dark.
D
Because
it
is
cheaper
to
buy
in
Oregon
than
it
is
in
California,
but
no
that's
a
huge
issue.
We
do
have
a
task
force,
a
metro
task
force
working
working
on
that
to
see
if
we
can
somehow
work
that
into
our
CCL
model,
because
that
will
take
care
of
a
lot
of
health
problems
if
we
get
them
into
a
safe
and
affordable
housing.
I
think.
B
B
The
bottom
line,
however,
and
I
really
encourage
you,
as
senator
Watson,
set
to
talk
with
your
Medicaid
director,
because
there
are
a
lot
of
components
that
are
called
supportive
housing
services
that
can
be
delivered
to
keep
people
once
you
find
them
an
apartment,
keep
them
there
help
them
understand.
They
have
to
pay
rent,
how
to
get
along
with
their
landlords,
how
to
stay
in
the
housing.
So
Medicaid
can
pay
for
those
supports,
and
it's
really
critical.
We
don't.
B
Typically,
we
haven't
taken
advantage
of
that
flexibility,
but
it's
one
that
I
think
we
really
need
to
get
better
at
because
we
know
this
is
driving
so
much
r
ER
visits
are
coming
from
those
people
who
are
homeless.
That's
really
what
is
coming
from
our
super
utilizers
are
typically
not
unstable
housing.
So
I
think
this
is
a
conversation
that
needs
to
happen.
It
is
happening
at
a
lot
of
state
levels.
B
It
is
also
happening
at
the
federal
level,
but
it's
not
and
not
in
the
way
of
just
sort
of
pulling
money
and
everybody's
going
to
be
happy,
but
they
are
trying
to
talk
how
we
can
should
have
work
around
it.
So
I
really
encourage
you
to
get
active
on
that,
because
it's
going
to
be
one
of
our
critical
issues.
B
L
I
just
like
to
make
a
point
of
clarification
that
leads
into
my
question
the
10
care
survey
that
they
quote
that
shows
95%
actually
terrible
methodology
on
that
study.
They
actually
use
like
it.
If
you
look
at
their
heated
surveys,
it's
closer
to
fifty
to
sixty
five
percent
satisfaction
rating.
So
just
but
that
leaves
in
my
question,
because
I
told
you
I
did
morning
I'm
sitting
up
to
the
microphone.
L
It
leads
into
my
question
because
you
know
we
try
out
all
these
different
reforms
in
these
innovations,
I
mean
we
have
our
payment
reform
in
Tennessee
and
particularly
when
you're
looking
at
something
that
is
a
multi-billion
dollar
budget.
That
is
usually
a
global
budget.
I,
don't
know
if
every
state
utilize
a
global
budget.
I
know
we
in
oregon
do.
But
what
you'll
see
is
a
for
example.
Ours
was
a
10
million
dollar
savings
really
round
number.
L
It's
awesome
kind
of
coincidental,
then
it's
also
on
the
same
page
right
next
to
150
million
dollar
increase
for
this
just
amorphous
health
care,
inflation
expenditure.
What
kind
of
data
are
you
going
to
request
from
your?
Should
legislators
be
requesting
from
their
Medicaid
programs
to
actually
be
able
to
demonstrate
that
it's
the
innovations
that
are
leading
the
state
that
are
actually
realizing
these
savings,
because
when
you
utilize
a
goal
budget,
sometimes
it's
hard
to
really
isolate
those
those
parts
and
it's
a
complicated
thing,
I.
Just
wonder
what
what.
D
About
the
CCOs
are
paid
per
member
per
month,
a
set
fee,
and
they
have
to
then
for
the
following
year.
That
amount
cannot
increase
more
than
two
percent
per
member
per
month,
so
that
so
and
so
far
in
the
two
years
our
ccos
have
been
maintaining
that
it
had
been
five
point:
four
percent
per
member
per
month
each
year
they
have
decreased
it
two
percent
and
they're,
going
to
decrease
it
two
percent
for
the
next
year.
D
J
You
I'm
Janet,
hey,
blur
registered
nurse
and
staff
with
the
American
Nurses
Association
of
my
questions
for
Senator
Anderson.
It
has
to
do
with
metrics.
You
alluded
to
changes
in
the
kinds
of
outcomes
that
you
were
measuring
and
if
you
could
just
elaborate
a
little
bit,
what
did
you
let
go
of
and
why
and
what
did
you
want
to
add
or
did
add
I.
D
D
G
D
D
At
funding
for
that
also,
but
we
found
that
one
school
district
they
do
build
for
their
services,
they
have
a
one
nurse
and
they
bill
for
their
services,
and
they
only
focus
on
those
patients
where
there
is
good
reimbursement
for
and
they
are
able
to
fund
their
school
nurses
just
from
by
billing
Medicaid
intro
great.
That
is
something
new
yeah.
B
At
both
of
these
websites
and
finding
out
more
and
asking
these
folks
throughout
the
meeting
more
more
detail
just
want
to
remind
you.
We
talked
a
lot
today
about
a
lot
of
different
concepts:
payment
reforms,
data
and
metrics,
I
think,
is
really
critically
important
and
the
oversight
and
accountability.
Where
is
the
accountability?
A
When
I
think
our
panelists
for
a
job
well
done
this
morning,
that
great
information
coming
from
the
state
of
Alabama
I'll
tell
you.
One
of
the
challenges
that
we
continue
to
face
is
the
cost
of
innovation,
because
we
continue
to
do
a
lot
of
both
of
things
that
we
talked
about
and
we're
really
struggling
going
into
special
session
to
get
on
Monday,
trying
to
figure
out
how
to
fund
transitioning
our
innovative
system
to
the
innovative
system.
A
So
I
know
that
we
all
have
different
kinds
of
challenges
that
we
are
facing
related
to
Medicaid
I'd
like
to
thank
the
health
resources
and
services
administration
for
sponsoring
this
session
today,
and
it
was
very
informative.
Next
I'd
like
to
invite
you
to
join
us
in
room
1
87
to
learn
everything
we
need
to
know
about
the
Zika
virus.
So
we
will
start
that
promptly
at
ten
thirty
room.