Washington, DC, 17 April 2006

Don’t know what to expect from this self-aggrandizingly named meeting. I’m familiar with medical association meetings, where politics and policy predominate, as well as research meetings, with endless paper presentations. But this one’s organized by a for-profit firm called World Congress (www.worldcongress.com) and features lots of big names (government and business, mainly), promising to offer a ‘dynamic curriculum of vision, strategy and execution road maps to improve health care quality, cost and access.’ Not sure I want an execution road map. But loads of people are paying $1000 a pop to attend.

The meeting is co-sponsored by the Wall Street Journal and Accenture, the consulting company that advertises on American TV using golfer Tiger Woods as their spokesman: ?High performance. Delivered.? Unsurprisingly, WSJ editors and Accenture executives will introduce or moderate several of the sessions. I signed up for a six month free subscription to the WSJ, so I?m not complaining. ?Gold? and ?Silver? level sponsors, such as UnitedHealth Group and CIGNA, also have multiple staff on the agenda.

12:00 noon

Big conference hotel in Washington. Registration goes smoothly and I?m handed a heavy logo-infested nylon briefcase with conference materials. Inside it is another logo?d up portfolio. This one has the agenda book. It?s the most complicated guide to a meeting I?ve ever seen?multiple tracks for different audiences, some open to all, some invitation only; all color-coded, printed on heavy stock and wire-bound. Weighs about two pounds. Took me days to figure it out. Best quip of the meeting was about the agenda book: Uwe Reinhardt, Princeton health economist, told the crowd that if the convention organizers had planned the D-day invasion, the Germans would have taken one look at the detailed, color-coded book and surrendered.

The main conference hall is huge, with two big screens flanking the speakers? podium, which is under colorful sponsor banners. What?s new to me is that the first 200 chairs or so are at tables with a laptop computer in front of each one. If you?re not sitting in the front, you?re handed a wireless PDA (by Palm, one of the exhibitors, natch) as you enter the hall. And if your badge has a certain code on it (mine doesn?t) you get a Palm Treo, fancier yet. A helpful attendant tells me these are not ours to keep (?they don?t work outside the hall?) but we will be using them to ask questions and respond to instant polls.

And it works. Some time during many of the plenary sessions a few questions pop up on the screen. You answer and push ?submit? and the moderator can then call up a bar graph with the audiences? responses. Sort of like the ?ask the audience? feature on the old ?Who Wants to be a Millionaire? show: instant collective wisdom. Neat.

1pm

After greetings from an Accenture guy, the opening plenary features the CEO of GlaxoSmithKline, J.P. Guarnier. He tells us about three people: a South African baby with AIDS who needs antiretrovirals, a British woman with breast cancer who needs Herceptin, and an American man whose son has a rare disease requiring an orphan drug. It?s not about business, he says, but about access (to pharmaceuticals, one presumes). Guarnier calls for national health insurance for the US, at least for catastrophic events. This makes the papers the next day.

2pm

Accenture is in the spotlight again (sponsorship has its privileges) in the next session, in which their partner Dr. Peter Kongstvedt, a witty and fast speaker, runs through a list of 14 or so ?top ten? issues for payers and providers, like controlling administrative costs, managing growth, moving to the retail mode, and customer satisfaction. Presumably if you hire Accenture they can help you with these. Kongstvedt was introduced by Karen Davis, president of the Commonwealth Fund, one of several heavy-hitting academics who have strangely minor roles in the meeting.

3pm

Dr. Francis Collins of the NIH speaks next about progress with genome mapping and genomic medicine. I was hoping he was going to tell us about actual patients who have been helped by the genome map. He doesn?t; but it?s coming real soon. His example is that we?ve now found genes that explain almost 75 percent of the risk for age-related macular degeneration, a common and debilitating disease. Maybe that will lead to earlier diagnosis and treatment, or even prevention. Diagnostics are one goal of genomics, as are customized pharmaceutical dosing regimens according to genetic make-up. Gene therapy, he says, is difficult and still a way?s off. Collins concludes by predicting that genetic medicine that is ?predictive, personalized, and pre-emptive? is coming soon, not 10 years from now. It was an interesting presentation.

The next presentation is puzzling. Given by a ?respected scientist and seasoned entrepreneur? named (I?m not making this up) Astro Teller, it seems to be about wearing whole body suits that monitor and report body functions. I can?t follow it and leave for the ?networking? break.

At the break I network with a Wall Street Journal reporter who is on the program later in the week. I ask him what the purpose of the meeting is, why the WSJ co-sponsored it, and who is attending. He says he doesn?t really know much about it, that his bosses asked him to moderate a session, and he thinks that most of the attendees are from health plans and large group practices.

4:15pm

The next session is about transparency in health care quality. Marc Volavka from the Pennsylvania Health Care Cost Containment Council gives an amusing talk about the four Ps in the chaos of US health care, all of whom are unhappy: providers, purchasers, patients, and payers. Another P?politics?trumps everything, he says, but public accountability has worked in Pennsylvania, leading to decreased hospitalization rates. Christopher Queram of the Wisconsin Collaborative for Healthcare Quality gets the speakers? bad luck award for losing both sound and lights during his presentation of the multiple reporting schemes they have in Wisconsin (divine retribution?). Finally, Dr. Mark Rattray of UnitedHealth Care (another sponsor) describes how United rates its doctors on quality first (they get a star in their web ratings for that) and then on efficiency (a second star).

One of the blessings/curses of going to a meeting in your home town is that responsibilities beckon. I go home for dinner, missing a keynote on avian flu Dr. David Nabarro of the UN and CDC director Dr. Julie Gerberding. I wasn?t invited to any of the invitation-only dinners anyway.

Tuesday, 18 April, 8am

On the way in this morning I run into the senior staff physician of a large American medical society. I ask him what he is doing here and what type of meeting this is. He says he isn?t exactly sure what kind of meeting it is but that he had come to hear what the health care purchasers and payers had to say. He had an inkling they were starting to figure out that primary care doctors are part of the solution to their financial problems.

At breakfast I sit with a group of staff from CIGNA, a large insurer, including their chief medical officer, who is speaking later in the week. They have to leave shortly after I sit down as their boss, the CEO, is in the first plenary session.

This morning?s purchasers? plenary started with the CEO of Verizon, Ivan Seidenberg, immaculately turned out, who cautiously reads his prepared remarks. He says Verizon spends $3.4 billion a year on health care for 900,000 employees and their families, which has gone up 28 percent in the last three years. He is searching for health care that is available 24 hours a day and uses information technology to empower consumers, with price transparency and plan portability. He?d like to see the fiberoptics his company installs used to make universally available electronic medical records a reality. He loosens up a bit during the discussion and admits that Verizon would really like to ?get out of the healthcare business? and just pay someone to do it?well.

A different approach is then presented by Michael Critelli, CEO of Pitney Bowes, who tells the story of his company?s journey from ?managing costs to managing health.? For their major factory groups, they have full service onsite medical clinics providing health screening, immunizations, and chronic disease management, fully coordinated with employees? personal doctors. This has reduced illnesses and hospitalizations in their workforce. In the discussion, Edward Hanway, CEO of the CIGNA, agrees, saying that we have to move from managing care to improving health, individually tailoring benefits and incentives for different types of people. A representative from Kaiser Health Plans points out that fully 40 percent of their costs are incurred by one percent of their patients.

9:15 am

After an introductory commercial from the CEO of a Nebraska faith-based health plan (an ?educational underwriter? of the meeting), the session begins with another distinguished, underused academic, Beth McGlynn from RAND. She introduces Dr. David Brailer, the Bush administration?s health information technology czar, who gives an update on his two years of work in Washington. His goals, he said, were to get people to understand what is needed in health IT, why it is needed, and then figure out who was going to do the necessary work to get it accomplished. Standards are being set, contracts have been let, and the goal is a ?smooth, private solution? to US health IT needs. The day after the meeting ended, it was announced that Dr. Brailer had resigned and was returning to California.

Dr. Robert Pearl, CEO of the Permanente Medical Group, says that it is a myth that medicine is different than other businesses. The same rules apply. The goal is to change care from episodic to continuous, and electronic records are an important part of that. Dr. Glenn Steele, CEO of Geisinger Health System, says that some sort of ?force function? is needed to move IT into use.

On the way to lunch I run into Dr. Paul Wallace, who directs health and productivity management programs for Kaiser. He points out that the average person spends two hours a year in the doctor?s office, 2000 hours a year at work, and more than 4000 hours a year at home. So if you do the math, an intervention at work that is only one hundredth as effective as one that doctors do could still be ten times more effective. Maybe concentrating on moving the parking lots at work and offering salad bars makes sense after all.

3:30 pm

Dr. Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services ?debates? Princeton?s Uwe Reihardt on innovation versus access. Turns out it?s not much of a debate, as no one is for price controls and no one is against innovation. They both agree it would be good to pay for clinical outcomes rather than for ?piecework,? but that it?s not easy to do.

4:30 pm

The buzz rises in the hall as the final keynote speech of the day approaches, by Dr. William McGuire, CEO of UnitedHealth. The topic is consumer choice, and after an entertaining introduction by Michael Millenson, McGuire takes the stage. He gives a bravura performance, effortlessly moving through dense slides that he comments on but doesn?t read. In fact, it seems like he doesn?t even have notes or a text. He speaks quickly but coherently about the complex, interacting health care system he?d like to see, which would offer accessibility, affordability, quality, and usability.

It?s pretty ironic to see him up here speaking under a Wall Street Journal banner, as he is on the front page of that paper today (which everyone has seen because we got a free copy as we walked in) in a long biographical article following up on their expose on him and his stock options last week. He?s clearly the rock star of this meeting, with flashbulbs going off as he speaks. He sticks to the topic at hand, though, and none of the computer- or PDA-submitted questions ask him about his financial dealings.

Other speakers for this session include John Brennan, CEO of the Vanguard Group investment management fund, who analogizes consumer choice in health care with consumer-directed retirement accounts. He says consumers are smart and do well directing their own retirement funds and they should be able to direct their health care too. These remain unproven assertions, I think. Another consumer guru, Jim Guest, president of Consumer Union, admits that ranking toasters is not the same as ranking hospitals but asserts that some of the same criteria apply. I think this session was brilliantly programmed by the conference staff. It didn?t work completely, but it did make me think.

Wednesday, 19 April, 9am

Last day of the meeting. In a session on chronic care and disease management, Bob Ihrie, compensation and benefits vice president at Lowe?s, a big home improvement chain, tells us that he expects an ROI (return on investment) for his health care dollars, which go to pay for health care for 72 percent of their employees. The best investment is in disease management programs for the common, costly chronic diseases: CHD, DM, COPD, asthma, low back pain, and depression. I wonder what you do if you have two or three of these?enroll in multiple disease management programs? Anyway, he says, he gets a 31 percent ROI for these programs, mainly through decrease visits and hospitalizations.

Dr. Jeffrey Kang, chief medical officer of CIGNA, says that diabetes is the crucial component of their programs; they pull data together from multiple sources to track it: laboratories, health risk appraisals, pharmaceutical claims, and more. He figures they get an ROI of 10 to 30:1 for what they pay for the programs.

Barbara Hoffman from CMS speaks next. CMS is clearly the big kahuna, paying out over $300 billion for health care last year. She directs CMS? chronic care improvement program, a huge randomized trial of 20,000 Medicare enrollees, each of whom is in some sort of disease management program. It?s called Medical Health Support. Too soon for results. She makes the point that Medicare patients with five or more chronic conditions see an average of 14 different physicians and get 57 different prescriptions a year.

Dr. Edward Anselm, who works for the HIP health plan in New York, focuses on smoking, advocating a ?conceptual transformation.? It, too, should be seen as a chronic disease. He says their programs get a quit rate of 15 percent after one year.

12:00 noon

I sit down for lunch with a semi-retired ophthalmologist who works as the director of a patient-hospital organization (PHO) in Maine. He says the meeting has been great, that he came to listen to all the bigwigs and has learned a lot.

My overall impressions of the 2006 World Health Care Congress are of a lot of business suits, a lot of money being invested, and a lot of smart people trying to drive down costs, make a buck, and also improve health care quality and outcomes. Everyone seemed to be talking about patient-directed care, consumer activation, consumer choice, whatever. I didn?t see a lot of evidence that it produced lower costs or better outcomes, but I couldn?t go to all the sessions. The meeting continues into the afternoon, with a speech by the Bush administration?s Treasury Secretary, and a videotaped presentation by the President himself. But I have to go to clinic, so I take off, turning in my PDA as I leave.