We're pleased to have with us today Karen ignominy president and CEO of the Group Health Association of America the oldest and the largest trade Association for hmos and similar Managed Care Systems Prior to joining GHA a Mythic Nani directed The AFL-CIO Department of employee benefits. She was a staff member of the US Senate labor and Human Resources committee. She has served as an assistant director for the committee for the national health insurance and as a health care research analyst for the department of health education and Welfare.Physic 90 was a member of the US Department of Health and Human Services Social Service security advisory committee and services serves on the u.s. General Accounting Office Healthcare advisory committee. She holds an MBA from Loyola University. Karen has been in the middle of a tornado for the last couple of years representing GHA a and watching her coalesce and build consensus around topics and issues that are very difficult to build consensus around has been a real treat for some of us. Following her presentation questions will be addressed from the audience Jane Mara second, Gloria McLennan of the Minnesota meeting will move among you to take those questions. You may use the slips of paper at your table to jot those ideas down and then we'll bring them forth. It's my pleasure now to introduce his care and ignominy. Thank you. Good afternoon, and good afternoon to those who are listening By Radio. I thought quite a lot about how I would begin my presentation to appropriately capture the mood of what I'm going to be talking about this afternoon and the quote that really popped into my mind and if you pardon me, I'll bastardize it. It's the windshield Winston Churchill line that you can always trust the Americans to do the right thing. Once they've tried everything else if I could give you a sense of where I think we are in healthcare policy. I think that quote really does probably very in a very pithy fashion capture the challenge and the opportunity. I'm delighted to be here today. I can think of few places more appropriate than Minnesota to discuss so where we've been and where we're going in organizing and implementing Public Health Care programs in this nation. This is a state which has pioneered Innovative programs to bring excellent Health Care to millions of people. This is a state where people in this room have set a standard for the rest of the nation. And I think that that is not often enough and knowledged. I'm proud to be associated with our member plans in the state and their leadership many of them are here today. I won't take your time to name them all but I do want to acknowledge the influence the direction and the real inspiration that I have taken in my role at GH a a from each and every one of my colleagues who are here who are part of our organization. I think it also goes without saying but I think it's worth acknowledging throughout the Century men and women from Minnesota have challenged the nation to think differently about government and about public programs Hubert Humphrey Walter Mondale the Mayo brothers many leaders in the business and labor communities who are here today, you've taught us what we can is people that we can as people make a difference working together for the common good and I think your legacy has born been born out of a track record. Performance, which is very important given where we need to go performance and accomplishment of people working practically and collaboratively and in the process. I think you've set Trends and showed that success is possible in collaborative fashion. We need that kind of inspiration now in Washington as we tackle very difficult issues. We could also use a dose of the Co-operative Spirit, which says the only way to find answers that will work is to work together. Nowhere. Is that more true than with Medicare which is the topic that I want to focus my remarks on today and in particular its prospects for reform, although I will acknowledge that much of the discussion. This far Medicare has been framed futuristically indeed with respect to the prospects for reform yet. I wonder how many of you agree. I certainly see the opportunity for improvement and strengthening Medicare, which is very different than a futuristic kind of discussion. We believe the time is at hand to do both and the fact is that we must again in this regard you have quite a lot to be proud of Minnesota is on The Cutting Edge in this community you offer have offered the nation a critical path for reform because in the Twin Cities area particularly their record numbers of Medicare beneficiaries receiving their care through hmos integrated Healthcare systems, that means that 50% of the seniors in this community are receiving more benefits than they were promised in 1965 and they're receiving care through systems, which do more than probably was envisioned back. Then their care is coordinated by a team of professionals that team monitors and works to manage chronic conditions. So important for the continuing independence of older Americans that team of professionals also delivers important preventive care to keep them healthy and provides the Specialty Care they need when they need it in this community for all of those. To cure beneficiaries Health Care is patient centered. It's organized and it's effective what's being done in this community and by more than 200 other organized medical delivery programs around the country today amounts to the goal standard that beneficiaries and members of Congress are seeking but I'm getting ahead of myself before we discuss the Future Let's recall what problems Medicare was designed to address? Let's discuss how it was organized and is organized and let's look at it through the prism of change that has occurred over the past 10 to 15 years in other public and private programs. I in preparing for the speech went back to look at some of the discussions that occurred on the various the both in the Congress in the House of Representatives. Well as the Senate and I also looked at what President Johnson said in signing the bill into law and I think that it's appropriate to quote from his words as a guiding. Sensible for what Medicare set out to do and I quote no longer will older Americans be denied the healing Miracle of modern medicine no longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years no longer will you know families see their own hopes eaten away simply because they are carrying out their deep moral obligation to their parents and to their uncles and aunts indeed. The program has prevented countless seniors and their families from going into bankruptcy and it has delivered the miracle of modern medicine to our nation's elderly now having established that some of you may say why mess with success why change it the answer is for two reasons first revolutionary changes in how health care is organized and how services are being delivered have left the traditional Medicare program seriously behind the times. Because we are treating more people outside instead of in inside hospitals yet. We have a benefit structure focused on inpatient Services because we have learned the importance of preventive care and management of chronic conditions to keep people healthy and living independently longer yet. We have a benefit structure that doesn't cover many of these important Services because and perhaps most importantly their data collection over the years. We have recognized the number of unnecessary and dangerous Health Care interventions and yet we have no consistent way of tracking outcomes or what is happening to beneficiaries being treated in countless individual doctors offices who are not part of coordinated systems. The point is that Medicare was an enormous advancement in 1965, but it has fallen behind in 1995. The other reason we must move to strengthening and improving the program is the one that gets all of the attention today and has gotten all the attention thus far but I do think in get seeking that attention. We do have have missed some of the underlying issues and that is the prospect of the program going bankrupt after the turn of the century. Now, I think it is unfortunate that this is the question that has received most of the political scrutiny thus far because the time is at pan to update the Medicare program in any way to update it to reflect the healthcare world of 95 the healthcare knowledge of 95 and the health care choices of 1995. I think this prompts a fundamental question that is and will be at the core of the debate both in Washington and communities like this all around the country and that question is should beneficiaries choose from among integrated Healthcare System. Or should they assemble their Care on their own by selecting from among countless individual Healthcare Providers. We believe in the end that this decision ought to be left with beneficiaries. On the other hand, we do believe that one choice is in fact better than the other Integrated Health plans as you have developed here in Minnesota offer clear advantages and I've mentioned some of them already. Let me reproduce some of the points and add some others first coordination of care in terms of teams of professionals Physicians nurses and other Healthcare practitioners working together to advance the health care of senior citizens and their families a very important and distinct approach to the service delivery preventive care emphasis on keeping people healthy not simply treating them when they're ill but there are other benefits to the individual and to the nation's Health Care System Integrated Health plans, as you know, well here can compete with one another on measurable variables such as quality service and the training and experience of their Affiliated providers. Integrated Systems include record keeping which has been impossible in the disorganized Healthcare System of the past today. It's possible to maintain quality assurance through analysis of healthcare outcomes and other variables, which we know are important to produce first-rate care. Without these systems. It's basically Caveat Emptor neither the individuals receiving the care nor the nation paying the bill can accurately judge whether quality and accountability are present you here in Minnesota have figured this out more than the rest of America. That's why you have led the way in opting for Integrated Health Care Systems increasingly employers and employees are also choosing such plans and some of the nation's finest and most sophisticated corporations have led in the shift. Excuse me today more than 50 million Americans are in hmos and while 22% of Americans in Private health care plans are members of hmos only nine percent of beneficiaries in Medicare are receiving their care in this manner one. Look at the federal employees health care benefit plan also tells a very different story in just ten years from 1983 to 1993 enrollment in managed care more than doubled and Federal. I have literally dozens of plans to choose from the fact that the Medicare system lags behind in this shift integrated care plans is one of the key reasons that the system is in trouble. We believe we can strengthen and protect the Medicare program for the future by giving beneficiaries the same choices that people under age 65 have we think they should have the same choices as those who are employed by the federal government. They should have the right to choose from among the full range of health plans available in the marketplace now clearly, there are those who have a stake in preserving the old system who will raise countless objections. They will try Scare Tactics aimed at those who are naturally concerned about change. Even if change is for the better, they will try to wheel their political muscle to stop reform of the Medicare system just as they've tried to stop reform in the marketplace. But if one cuts through the smoke screen and measures change using a standard of what is right for beneficiaries which in the end there can be no other standard then I predict the right changes will come and the changes will come quickly one factor propelling events faster in Washington is that we have moved to a discussion about policy. We must continue to approach Medicare that way or else we will bog down and we will fail you need to watch the key committees and you'll be able to see for yourselves whether we're making progress in the Senate the key committee will be the finance committee in the house. It's the ways and means in the Commerce committee's we in the HMO Community are working on both sides with members in on both sides of the political aisle, simply put our objective is to protect and preserve Medicare and offer more choices to beneficiaries by bringing the program up to date Medicare should reflect the overall Healthcare market and its advances of the past. Three decades our policy goal is to establish a market where beneficiaries can choose among competing plans that actually compete on the basis of service quality and price in my view that's progress that we can Embrace for our elders and we can look forward to ourselves. We are at a Crossroads as a nation. The promise of Medicare was laid out clearly by Lyndon Johnson in 1965, and we need to move forward in that tradition. We know what works now we need bold action and Common Sense bold action to tackle and fix the problems now common sense to use the solutions that are working in the private sector for millions of people and we need a spirit of cooperation. Together in an approach that transcends partisanship if we take these approaches we will succeed. Our elders will have peace of mind and we will be proud of our accomplishments. Thank you very much. Thank you, Miss. Ignominy. We have some questions now from the floor for our radio audience. You are listening to Karen. Ignasi who is the president and CEO of Group Health Association of America. Our first question here is from Lee angstrom. Who is the medical director at United Healthcare late. Karen now there's a perception out there that at least that I hear frequently that there's no choice when a senior enters the HMO. Could you talk about the facts behind this? Is it myth or is it reality? Yes. I appreciate the question. Latest is for the record. Dr. Lee newcomer who's with United Health Plan. I think that you've hit on one of the most vexing issues as we talked about the need for change. We actually took a look at some of the materials that beneficiaries get upon turning 65 and frankly to say that one would be confused would be to understate the the facts. I think what we need to do is to step back and on reaching the point of 65 and becoming Medicare eligible individuals need to get the kind of information that federal employees get for example with respect to the array of health plans that are out there in the market the information that is available about plans and then begin to make choices one plan to another And make the choice most importantly that's right for them. The beneficiaries need to maintain the ability to choose in this system. But we need to in terms of the restructuring Challenge and much of this can be done. Regulatory Ali and some must be done legislatively but to move forward to offer that Pantheon of choices if you will in a more organized kind of environment. Thank you. Our next question is from Jeff Arnold. Who's with Mitsubishi Bank missing Nanny. Would you please comment on the status legislation as it moves through Congress what bills are being presented? Who's sponsoring it? And who's pursuing it? I think again, that's a very good question right now. The much of the discussion has been very much focused on the budget that is not because I believe members of Congress necessarily want to start out that way. It's because of the nature of the budget process which has to move forward in the spring. What I tried to do in my remarks is to talk about how pleased we are that now the discussions are moving to the underlying policy issues and from conferring with members of Congress. I think they are also pleased that now we are getting to the opportunity to have interactions with senior citizens with the business Community with the Healthcare Community about the challenges before us the range of Alternatives and how to proceed thus far there have not been a very many. Cease put forward yet in terms of Medicare restructuring our organization along with others hopes to be very helpful in that in terms of offering new ways of thinking about creating and the objective I guess if I could synthesize is to create a market or beneficiaries can enter a market and choose among a range of options that is not the situation we have today that would create a situation that is much more consistent synergistic if you will with what is going on in the under 65 market and what you've probably done for your employees and senior citizens from what we know based on the experience in already in health plans are very very pleased with the opportunity to make those choices be more aware of them and have the information out there on the part of all parties. I might say it is not going to help us make changes. I'll just say parenthetically that if we go forth embarking on a new Medicare system and embarked upon the challenge of creating a market where if We only have information for managed care plans. We have to get information from the fee-for-service plan. We have to get in under what's going on that back black box and we have to have information from all the various plans that want to participate in the market. So we are talking about informational requirements that will be very very key but are not cannot be only for a certain sector of the market. Thank you missing Nanny. We have a next question here from Bill slice and bills with a company called met until supplies Hospital information systems. Is that right bill? Missing Nanny if you if you could summarize I guess how do you see the benefits being administered? More from more from the perspective of how is it different from it is today. What is your proposal in terms of how the benefits would be how how a senior could choose which plan they want to to participate in and and how the benefits would be paid for and administered. Let me answer your question to begin by contrasting with the present system, which is pretty much that individuals who are Medicare beneficiaries basically seek doctors from the phone book. What we are talking about would be a tremendous step forward to provide organized information in the way information is provided to federal employees where they have a full range of health plans to choose from understand the benefits that are offered by those plans. They would be spelled out and there would be quite a lot of competition among plans on the so-called area of supplemental benefits if the congress makes a decision to begin the To focus on Market if you will around the proposition that all plans should be required to offer Medicare benefits as a Baseline and that let plans compete with one another by offering additional benefits. Then that will create a system which is very much akin to the kinds of systems we have in the under 65 situation that would mean that quite a lot of the program would be administered by the health plans themselves. Thank you Mythic 90. Our next question is from Tim Penny former congressman from Minnesota. You you probably know better than anybody else about what's going to happen. You should be up here. No, I'm glad you're up there and I'm glad to be home in Minnesota. You mentioned that you wanted to focus more on policy. But the debate is being driven quite a bit by the budget both the House and Senate talked about budget cuts in Medicare. Well Cuts if you cut from the Baseline in excess of 250 billion, some of that is by means testing or assumed to be by means testing some of that by some co-payments perhaps but a big chunk of that from the assumption that we will place more seniors into managed care. I'm just curious to know how realistic those savings estimates are. Well, I actually have a view about that question that has been formulated by going around the country and talking with Ben. Fisheries who are currently in Coordinated Care environments Medicare beneficiaries and remember their about 9% of them as you know, and what they tell us they like is the notion of a teams of professionals working for them to help them navigate a complicated delivery System point number one having information being able to compare one plan to another and not feeling that they're sort of floundering on their own trying to figure out how to go from specialist to specialist is going to treat an isolated bodily part. That's what they tell us. They like I am absolutely convinced based on that and looking at the outstanding patient satisfaction rates that are plans are receiving from beneficiaries who have made the decision despite this lack of information to seek care through our plans. I'm absolutely convinced that more and more beneficiaries will actually vote with their feet and move to more Coordinated Care and integrated care environments now on what schedule over Period time you're getting to I think the heart of the matter and I'm not in the predictions business. Although I think it's challenging and inviting to sort of step into that in a situation like this. But I think the reality is that what we need to be focused on a speaking from the industry perspective is to create and be helpful in a debate sharing the information that we have gleaned based on per having an established track record that is exemplary and trying to transfer that experience to the Medicare area and putting our plans out to senior citizens and allowing them to choose I can tell you in the federal employees area in 10 years the numbers of people in hmos have more than doubled in 10 years. Now. I know that and you know that the rates of increase with respect to individuals who are over 65 now going into integrated Healthcare environments. It's increasing by approximately 20% per year. Far faster than the 13 percent a year that's being brought in on the under 65 market in terms of what beneficiaries are doing in the choices. They're making so seems to be a lot of excitement within the senior citizen Community. I'm very hopeful I think that as we've worked with the leadership on both sides of the political aisle, what we've been trying to do is to be helpful based on the data that we've collected the research that we currently have on going about this matter of how many what schedule what time and ultimately it boils down to individuals building a model to basically predict Behavior what we think I think we can contribute aside from that issue which is fairly clear-cut depending upon assumptions. Well, I think what we can contribute is a sense that we have determined that the track record of Managed Care has really not been fully appreciated by individuals who are looking at this as a model. For public programs and what I mean by that is we are only now scratching the surface about what I would classify as the spillover effect of what our plans have done in markets and how that has affect the non Managed Care environment. We have just we're in the process of concluding a research study that has been done by a very well-known actor in very well respected academic that has determined some very extraordinary results with respect to spill over. So rather than being the follower in the delivery system. Now, what we're seeing is that our plans are becoming the pacesetters which I think offers real promise in terms of getting the cost down, but most importantly getting quality up coordination up and a sense of getting under that black box and knowing what is out there to be purchased the very different system. Thank you, Miss. Ignominy. We have a next question from John Tyler and John has with boys and Tyler a Financial Group. Thank you. Mrs. 91 of the some of the feedback that I have received from my clients that are involved in hmos and from their employers as there's a tremendously high demand for Unnecessary care primarily because of the rich structure of the the financial packages that are put together. How do you propose that that the high demand for Unnecessary care would be curved for Medicare individuals when individual show an unlimited appetite for health care services when paid for by any third party payer, well, I actually think that's a very good question. Let me answer it in several ways first we have in the fee-for-service system. We have no mechanisms basically to determine to a track outcomes in experience or to determine the amount of care that is necessary. And that is become I think quite well established in the healthcare literature. We've all seen studies about the amount of unnecessary. Gary bypasses the amount of unnecessary hysterectomies the unnecessary C-sections and yet I think the people who perhaps have not yet fully absorbed. The implications of that are many of the beneficiaries themselves because the information really coming out about the consequences of unnecessary procedures has been fairly limited and not well discussed. I think in the popular press the more beneficiaries have information about that potential negative the more they have information about Coordinated Care and they are interacting in an environment that is coordinated where teams of Physicians are actually working on the whole person. It's very hard for a beneficiary standpoint to go to one individual to treat a particular condition. Then go down the street several weeks later to another there's no Central record-keeping in the fee-for-service environment again, no tracking of outcomes no systems. No coordination. So it puts the beneficiaries in the perspective of really letting the buyer beware. I think that we have now Hit Upon a better way of delivering health care and that's what I'm talking about, which is more coordinated gets the patient involved in a more informed way and has groups of providers involved in more effective and efficient ways than would be in the present system today at but it's certainly a challenge and moving more individuals in that direction in not just beneficiaries but individual Physicians themselves, thank you, Miss. Ignominy. Our next question is from Paul Bennett who's with the Canadian Council here in Minneapolis. Thank you to date you or at least so far in the meeting you've discussed Medicare and hmos. Just wondering if you could broaden that little bit too. If there are any prospects for some sort of national plan in Washington either the administration or congress because clearly hmos would be one. Back to vehicle to help promote that Congress in pain. Do you want to take that question? I actually I'm not sure I guess people from Washington rarely say those words given the way the debates have been going. I think that the matter of moving toward an access program universal access or some State critical path on the way. There is really is a budget issue is a financing issue. And actually I have always wondered that if the president did not go ahead in the first year of the administration with a budget proposal and were savings and resources available for Health Care would we have had a different experience? I think that also what needs to be said is much of the Clinton program was very budget driven in terms of not actually having the ability to raise taxes or do things at Internally and that's why I think the program was crafted the way it was. So this is a very very important matter that you've queried one that I think really is terribly important to attend to from a matter of public policy. We know the men the numbers of people without Health Care protection are actually now it's over 40 million where whereas a year or so ago is in the 37 million range. So we're seeing extraordinary increases, but I do think it's a matter of budgets. It's a matter of financing and unless as a nation we can come to a decision about how to take on those questions and I fear that they will continue to elude us. That would not be my preferred strategy But endeavoring to answer the question. I think that that is a real challenge. Thank you Miss. Ignominy. We have a next question from Mike Freeman. Who's the Hennepin County attorney? We've heard a lots of huge numbers being bandied about Washington's potential savings. It's kind of hard for all of us to understand how you could save this much from the system merely by reform and that it wouldn't impact either the quality and the quantity of care for our seniors. Could you comment? Yeah. Well the proposals have been to take down as you know the rate of increase and I think that that's an important point that thus far again has not necessarily been fully appreciated than debate. I also think that there is quite a lot of issues with respect to how we approach the challenge of the amount of unnecessary care that is being dispensed in the name of high quality. Any medicine which in a Coordinated Care environment, it offers you an opportunity to set up systems to do continuous quality improvement feedback information and actually make sure that teams of professionals are practicing in appropriate fashion in a fee-for-service world or a traditional old-style Medicare program. You don't have the opportunities to actually step back and look at that. It's not necessarily patient-centered either because the driving force is from the healthcare provider not the patient. What we're trying to do is to offer some proposals to members of Congress. That would be more patient centered that would put this patient in the center of the choice scenario and have plans complete compete very aggressively on service on quality on outcomes, which would bring us to a point where we would be able to get our hands around some of the issues that you've probed, but I really want to make Point that we will be kidding ourselves. If we think we can do this by having managed care plan compete against managed care plan. We have to have standards and information and competition across the board across the system starting with traditional Medicare and running all the way through the full gamut of plants. And that is a tall order. We're talking about tremendous infrastructure reform, but not that we can't do it. It has been done now in the private sector and done very deliberately and very and relatively fast indirect fashion, but we need to move in the same way and public programs. Thank you. Our next question is from dr. Jim Allen. This question also has to do with the concept of Coordinated Care that you've mentioned and it's broader than just Medicare. It's been stated that for each out-of-pocket dollars in this country that's spent on traditional Healthcare Services. Another dollar is spent on non-traditional Healthcare Services. Would you comment on the Assimilating non-traditional types of care delivery into the sorts of systems and solutions that you've been talking about. Yeah. This is a real risky one because I may give you an answer that is not the right one from your perspective. But I think to returning it back to you Jim I think as I observe your systems and others one of the things that I think is most exciting is the sort of movement Beyond acute care and into other kinds of benefits potentially ranging all the way to long term care what you've developed here in your plan. And others is Coordinated Care that works not just for acute care, but for all the other supplemental kinds of services and for potentially long-term care and very very exciting ways. I think that that's that is the goal standard. That's the right mix and clearly what works successfully in an environment needs to be transferred to all of these other benefits that we will not have done our job if we At coordinating only physician care for example and traditional kinds of services but we need to bring in Chiropractic and podiatric and all the other kinds of services that people are seeking but in coordinated fashion now that met many of the people in this room maybe from those respective communities. I know there's quite a lot of discussion and sometimes heated discussion within those communities about the prospects of moving into a Coordinated Care environment. But again, if we hold up the objective of patient centered care patient centered environment, so that's the only route for us and I actually think from a beneficiary perspective as I go around the country talking to people. I think that's what they find very very exciting about our systems and challenging Thank you voting with their feet. Thank you missing nanny for our radio audience. You're listening to Karen dig nany who is the president and CEO of the Group Health Association of America. We have a next question here for Shimon schneemann. Thank you agency and that's an insurance and Risk Management Group. Thank you. My question take so long to mr. Freeman's comment before but essentially in the past many buyers private buyers of healthcare have had to deal with a problem that many people have come to known as the cost shift in light of this impending budget problem that we've got and I've heard the number two hundred and fifty billion dollars thrown out. Could you comment on how a transition to more managed care with this large part of the health care dollar is going to help or hurt or change the status of the There's going to be another significant cost shift from government on to private buyers of health insurance plans well to the extent that the private buyers of Health Systems and services are actually in coordinated Health Care Systems that are responding to the challenges that have been laid down by the purchaser and Community then they have seen some real progress in that area and a rather dramatic Improvement in terms of the cross-subsidization issue. I will say however, there is a concern and I think it's quite legitimate among those providers that are not yet in Coordinated Care kinds of environments how they will be affected by the prospect of change. We need to analyze that we need to contemplate that and we need to put in place a transitional kinds of proposals that will move us in an orderly fashion from A to B. Now you didn't ask the In which I think perhaps is implicit in what you've suggested which is what are we going to do with research? What are we going to do with teaching? How do we fund these matters in these issues? And I think what we've been doing is we've had hidden kinds of subsidies with respect to those challenges and some others and the question I think for society now, which the Medicare debate definitely prompts. Your question implies is are we going to basically get to a discussion where we will be looking at funding those challenges directly Distributing the burden fairly and perhaps making some major changes in the way we've operated in the past with respect to particularly teaching with respect to research. I think ultimately there is going to be quite a lot of discussion between separating the social goal of teaching and research which we have to maintain in our society. It's one of the reasons that we have one of the best Health Care Systems in the world. From the business of running academic medical centers and without coming to you with a nice little wrapped up program here for consideration. I want to flag the issue because I think it will be one of the most difficult and divisive for a lot of different political reasons. So you're quite right to raise the question. We are a long way to actually getting to the point where Congress is ready to vote on a proposal. All these issues will be part of the consideration. But that shouldn't on the same day on the same token or in the same vein discourage us from moving forward. We've already established. I think as a society that the Medicare program is one that was very reflective of the medic of the market in 1965. It is no longer reflective the market in 1995. So even though we have the challenges, even though we have the difficulties it's time to sort of get on the road to moving forward, but we are prepared to enter into very serious discussions about these matters and don't intend to put Heads under the rug. Thank you missing Nanny. Our next question is from David. Zegen Hagen who's the president of the foundation for Health Care evaluation? And I'm going to step out from behind the post that I can see. It's very nice. You've talked about two of the key links that you've talked about in a changing system are full access to all different kinds of managed care plans for Medicare beneficiaries and a better informed group of beneficiaries. How do you see us working toward getting comparative quality of care information to beneficiaries in a competitive environment. Well in the HMO Community, I'm very proud to say because I think it's one of the only communities that I know of that has actually given quite a lot of deliberation to this matter by pushing forward the notion, excuse me of report cards of Data Systems where there can be sort of comparability of performance establish, and I think that that's a very productive and positive trend what we Need to do is challenge other systems to begin to work with us to establish some principle of uniformity with respect to information and other kinds of variables that will be very key to moving forward to actually accepting the challenge of making the Care Systems more patient-centered again, we can't simply end up. I think I hope you do as well with a system where we have one HMO competing with one HMO because they're this is the community that has pioneered information disclosure. That would be a terrible disservice to beneficiaries because we need to get our hands around what's going on in other systems as well. That's what I mean by uniformity of regulation of the kinds of infrastructure changes in response to your question that are going to be quite Monumental, but I find very exciting from a consumer point of view and from a standpoint of our Healthcare Systems one that is a very welcomed people. In the in our community began by offering services that beneficiary scrutinize and ultimately decided to accept and we are very very proud and pleased to compete in a truly fair and competitive market where you do have a Level Playing Field with ignominy. We have time for a couple more questions the question here from John Stone who is an attorney with Oppenheimer wolf and Don Lee. Missing Donnie with the development of Managed Care Systems has resulted in integration of providers which has been perceived as a threat very often by providers. It's resulted in the patient protection act and other types of any willing provider legislation around the country federal and state. Would you come in on that? Where do you see that's issue going. I this was a very as you know, very active matter for Congressional deliberation last year. It is seemingly also going to be a very active matter congress's mind this year. We have the view. I'll try to summarize it as succinctly as I can that our plans do make decisions about the providers that they will affiliate with they make those decisions because they hold out a panel of providers that they believe best meets the needs of beneficiaries. We're not embarrassed by that. We think that that is the right thing to do from a patient perspective and we're pleased to compete based on those. Jen's now for those that have proposed an any willing provider law which would basically require us to affiliate with any physician in a community. I guess. It's best described by talking about sort of an analog being any willing journalists or any willing lawyer or any willing. What have you researcher? We do not have a pattern this country where employers are required to hire any particular class of employees. If we are to move that way in the healthcare industry, I would think that many of you would share the view that that would be terribly disruptive set back to what we've been able to accomplish in the HMO Community particularly. It basically strikes at the heart of Coordinated Care and takes us back to fee for service in the end many of these proposals have been offered by those who are very concerned about the prospect of change and from that I think has derived the any willing provider proposals the so-called patient protection. Snack which if you read the bill isn't very much about patience, but quite a lot about providers and ultimately we have to decide whether we are going to protect providers whether going to protect consumers and where the balance is and we've been as you might imagine very actively engaged in that process. And the one thing I can promise you is that we will continue to be actively engaged in those processes and discussions in Washington and and in a States, thank you missing Nanny we have time for one last question dig Neiman who's a senior executive at Blue Cross and Blue Shield of Minnesota. And also on the Minnesota Healthcare commission dick you talked earlier about or one of the questions was on the cost shift from the private sector to the public sector and you talk to also about the black boxes reimbursement. What what advice are you giving Congress on Geographic variation so that as you've acknowledged Minnesota seems to be doing much better as far as the cost and the quality and how do we avoid perpetuating the high reimbursement rates in some? It's the country and then penalizing Minnesota and other states have done better. So how would you advise Congress on Geographic variation and reimbursement? The answer in the end is going to depend on sort of the shape of the Box in terms of the restructuring proposals, but we have begun to look at various models that have been present in other legislation to deal with special circumstances and special issues and certainly as we look around the country. There are many communities Minnesota is one, of course in there are others where the reimbursement rates have not kept pace with where they need to be to provide the full spectrum of patient services. So we are in the process actively now of really studying that taking a hard look and looking at what has been done in other programs to solve similar kinds of problems and I'm actually very hopeful that we're very close to being able to offer some constructive proposals to solve these Problems. Obviously, we have to solve these problems or we're not going to be able to move in the direction that I've talked about in terms of a beneficiary centered Choice system. So we're very cognizant of it. We've got some real active issues going in many of your people are involved in that and I think that that that's very good. We need them and we need we have around the table the people who have had the experience who have the commitment and have the wisdom to help us move forward basically, but it's one that we have to be very engaged and we plan to be Thank you Karen. I that's a wonderful set of responses to a bunch of tough questions before we let her off the podium. I would like to present to you. The Minnesota meeting peace pipe. This is crafted by Minnesota artist Robert Rose bear. The peace pipe is symbolic of the sorts of human bonds that we all need to work to create to solve problems such as that that we've been talking about for the last hour or so. Thank you very much.