Mark Frisse: Call me Mark, please. I haven't been a real doctor for eight years or so, unless I sent you a bill, it doesn't count. I have been here a lot. My other patients get me to Florida or at least gives everybody else a call. There's actually quite a few of us up in Nashville who look to Florida for a lot of leadership. And we benefit every day from the fact that the information that they make available is out there overnight.

The few times that I've had a good fortune with my governor, who was a real down to earth, practical guy, the one and first questions all the time is, "Mark, do you still go down to Florida a lot?" "Yeah and here's why. I'm going to go there tomorrow, there's going to be a meeting." Tomorrow night, he's going to be out there and see what's going on and da-da-da…he's kind of taking notes until it all rubs off. Be very proud of what you've done.

Tom has mentioned to you that this is going to be different. It is. I came up to help your guy, kind of left it all over the private sector, pharmacy, benefits and the health care IT consulting. Somebody from daycare here? He's supposed to be here. I worked with Steve Mason of THR for six months, actually, doing qualities right before he left. I know him very well. He's a real role model. I've met a lot of you and a lot of people you've worked with in various phases of my life. The thing I can't really say a lot about is that I am a Notre Dame football fan here. And so, I have the advantage.

Participant: Boo.

Mark Frisse:  Exactly.

Tom Lloyd: It's okay. That's okay.

Mark Frisse: In Memphis, Tennessee, we've actually known Mr. Sullivan and a lot of other people trying to wire up different areas of Florida. We've done that in Memphis, Tennessee. All these hospitals that came along or that worked that long, we have privacy and security frame working on side of good fortune co-chairs and passport, peer and that sort of thing. We've got it to work.

The reason we've got it to work was because everybody - I was from Nashville, this was in Memphis, 200 miles away - so everybody disliked me to the same degree. Everybody distrusted me to the same degree. And I think that's really important. As a health care guy, I'm going to sit here and I'm going to say, "Where is the agenda? What's the next set of power points?"

We have an agenda. Its like a chess game. Depending on how you guys work through the next session, we'll be changing that session after that onwards. We have a plan to get to action. You have to trust us on that. We've been working very, very hard on that. But it’s going to be defined by you.

Another thing, as a health care guy, I don't like, is that we always end up having the same old, same old fights. It's predictable. I mean. I know you guys, I'm sure you'll get along very quick, you'll manage; just don't rate the hospitals, no problem. Right? None. And it never comes out. I mean, no. Kumbaya. This is not going to be Kumbaya.

We're going to do one of two things: we're either going to delineate why we don't get along and deal with the reality of that or we're going to try to take a different act and wear a different hat for a while and look at ourselves as human beings and figure out where we got to go and figure out how we're going to get there from our various roles representing our constituents. Because I do believe there is one thing we all share that you don't have to do any wonderful years doing this and that's to say it's all broke, that's it's not going to work.

When people say about any particular aspect what is the sustainability model, I go, "There's no sustainability model in anything in health care. What are you talking about?" Some people have more money than others right now. Some are in the middle with more power than others right now. But that changes. That changes. It's all broke. So I think if you all start with that or if all needs to be fixed, we'll be okay.

So, we're trying to figure out how can we get people out of the usual thinking and think about this problem differently. Because the problem that Dr. Okinobi has put forth before you, transparency quality, price; how do you get the right information? How do you make that information available and meaningful? How does somebody understand that information and how do they go look at it? And then finally, how do they change that behavior? That's hard. Nobody's done that before. One of the reasons you’re frustrated is because we don't know how to do that.

So, we're trying to think of something we could relate to because all, just like in Memphis, they all just disliked us in the same degree. What is something we can pick on that will give some of the lessons? And we thought maybe it would be airlines. And for those of us who flew down from Nashville yesterday on Southwest Airlines, with something called the bottom room, adjustable, five days of people unwashed were on the plane with me. I felt like I was in a pilgrimage to the Ganges because I really freaked. And there was a woman about this tall who had been, I don’t know, she had a lot of green things, didn't have a little umbrella, and she was just speaking up, I don't know why. But she had issues.

But we all know air travel, right? Air travel is the closest thing to bad health care as I could think of on a bad day. So, we wanted to talk, you know in the institute of medicine had this book take care of human. And it really set the ground rules about just how dangerous our health is could be. So, we thought we'll just spend just a few minutes talking about airlines. And can we have the tickets? Steve?

We're going to put these under your chair but we were afraid that if we did we'll just lose one of them. Take one, just take one. Look at that. Study that carefully. Analogy: airline to health care. Have you ever tried to make sense of an airline ticket? Because it makes any sense. If somebody can explain their airline ticket to me the way they explained it to me. The only thing I know that doesn't make any sense is the hospital bill. Has anybody ever made sense of a hospital bill? We're not going to be sent the hard fact analysis but I think we can find more analogies about it one of the three reasons, I'm sure you got it, was will hospital throw their weight on the airline industry.

And take a look at that ticket; you should see a few things on it. Right? This is an airline ticket. Let's go to the next slide. You've got a price on there; what you paid for that ticket? You've got some issues of whether you’re first class or not; we don't worry about the magnetic fee. You've got a few determined about when you booked the ticket. There's a bunch of things that you can pick up a story about that. So, you all know your airline tickets now. Everybody has gone from Tampa to the DC area. We've all got a ticket.

Have you ever done this on a plane? Ask the person next door what they paid for their ticket? You can't anymore because the security people would have you cufed before you know what happened because it creates incredible rancor when you find out the variation in prices on an airplane. By the way, this is all Will and Peter's work, these slides and these good visuals and graphics. We've got so into this, it's about a week to remember that this is not a seminar on airplane prices and transparency. But the good news is if that health care continues to fail maybe this would be the start of a new career for you all.

Now, I want to ask folks what your ticket show, what you paid for.

Participant 1: First, I'm going on Super Airways and my ticket says a hundred and eighty dollars.

Mark Frisse:  $180. How about you?

Participant 2: $150.

Mark Frisse:  $150. What do you have?

Participant 3: $500.

Mark Frisse:  $500.

Participant 3: Same.

Mark Frisse:  First class? How'd that happen?

Participant 3: I bought online.

Mark Frisse:  Probably a hundred.

Participant 4: $150.

Mark Frisse:  $150.

Participant 5: I'm free.

Mark Frisse:  So, you're an agent of the State?

Participant 6: $150.

Mark Frisse:  $150.

Participant 7: $450.

Mark Frisse:  $450.

Participant 8: $150.

Mark Frisse:  $150.

Participant 9: $200.

Mark Frisse: $200.

Mark Frisse:  $150. We've got a lot of good discounted prices. Why do we pay, show that whole prices list. These are the prices we can find. And this is the price range. Now, Tampa down to DC doesn't have the same variation if you would've gone to Little Rock, Arkansas with thousands. I mean, creativity you can do there, absolutely stunning. Why are there differences in prices on airlines? Does that make sense to you? Why is that happening?

Participant 3: Because they can.

Mark Frisse:  Because they can.

Participant 3: If they want to then as the seats get down, they charge more and more.

Mark Frisse:  What else? Any other reasons?

Participant 1: There's a lot of big money.

Mark Frisse:  They want to make money. How are they doing all that?

[Laughter]

Mark Frisse: One thing they all have in common, too, if you have an airplane ticket that doesn't make sense, it's probably a bankrupt airline. Did you notice that? I mean, I think I heard, globally, the overall revenues were like $400 billion and the margin was less than $5 billion or slightly around the 1% gross margin in airlines worldwide last year, but less than 1% margin for those of you in healthcare know that one.

Anything that is interesting about it is there are airline owners and losers. These airlines they can carve out certain routes, right? Just take the high things or certain clientele of the airlines and will have to serve everybody much like a public hospital. Or you have the legacy airlines with full facility with a DC9. What else is going on?

Participant 5: Timing.

Mark Frisse:  Timing? What about timing?

Participant 5:  Sometimes, depending on the airline, when you buy on the last minute you get it cheaper, sometimes if you walk up and buy at the last minute, the price is twice as much. It depends on the airline.

Mark Frisse:  Can you picture that in the ED. You come into the emergency and you might have that chest pain…hmmm, what's it worth to you? What was it worth yesterday? Did you know that they are full?

Participant 5:  No, for the same amount, they've adjusted the price based on the fuel. If fuel goes up, the stick goes up.

Mark Frisse:  We ought to say information technology is supposed to liberate us. But I think it's more like what you’re doing instead of the Chicago convention. In 1968 they said the police are not here to create disorder, they are here to preserve disorder. Could we have the attached instruction we have on America Today about computers?

It would have to be simple. It would have to make sense. It would have to be somewhat transparent. The only reason we could have something this complicated is because we have this weapons, for good or for bad, because we have incredible complexity.

Did you know that we found out there are entire industries of vendors that compete with the airlines in optimizing their prices to show them exactly how to change the fares and make a little bit of dollars even there. Okay. So, again, an enormous industry behind the scenes on commercial airlines, to kind of figure out -- because they're trying to survive, right? They're trying to survive. You want just to get the point A, point B. these people need to stay in business; the fuel prices, some have very expensive labor structure, have very expensive, so thats prices keep going.

Yes, please.

Participant 8:  I also think that part of the issue, there are sometimes like if you are flying in for a business meeting, you have no choice. And there might be only one airline flying over and you've got no choice because you want a vacation and you might get to shop around and advance, but I think that that too is and if you look at, for example, trying to get to Tallahassee, the prices are amazing if you can find a ticket that the other people have to buy because it's the only way to get there.

Mark Frisse:  It bothers you that it's cheaper to go to Paris than to Tallahassee?

[Laughter]

Participant 8:  Yes.

Mark Frisse:  I know which one she'd rather go to, but yeah. But, now let me ask you this, do you think you can have a competitive market between that flight to Tallahassee in Florida? Do you think you can have enough buyers and sellers to really make it more competitive?

Participant 9: They've tried.

Participant 3: That's one of the points, I think we steer from that, I used to fly in Philadelphia it was like a 1000 bucks that where there's no other airlines landing. Southwest started to land there. It dropped down back to 500, 250 bucks, that's what I'm thinking.

Participant 10:  If there are a lot of important people flying, some people don't pay for their ticket. I don't pay for my ticket if I have much less concerned about.

Mark Frisse:  So, if you're not paying for your ticket, are you going to pay a lot of attention to all these specialized websites to find out the optimum price? Probably not. It doesn't matter.

Participant 10: I'm going to know on this computer and they tell me which flight.

Mark Frisse:  The lesson number one is 80% of the population doesn't pay for their ticket, anyway, then you can do all you want about optimizing prices. Say, you don't pay, somebody who is paying for your ticket is going to start engaging some consultants to do that job, da-da-da…then you're going to have all these people you go to and now I know from my government contract, I go through the federal contracts, I go through agencies that I have to pay extra money to deluge my ticket flyer number and making it more difficult for me than if I book it myself. But that is because you don't get the prices, somebody else is in the middle of it. What else about airlines?

Let's go back to the small town. Do you think everybody get two airlines competing with this low volume? Probably not. It's what the market will bear. Unless you have the bus, more like two, no you’re not. At what level will you take that competition there? And unless we can watch their, in a sense go in and regulate the group like watching out a class that might afford a miracle about access. You know, none of us is transparent itself away with health unless you can really enforce pollution or in the case of the prescription side you’re actually going to get pollution. People drive a thousand cars. Yes?

Participant 6: I think, too, Paris as you've noticed, I wasn't talking about Tallahassee, a number of years ago our city subsidized an airline into the city and they gave them a five-year deal in terms of tax rates on actual gas subsidies. The airline stayed there right up until the cash was signed and then left right after the gas subsidies were finished. And prices were low while they were there because they sure were in place.

Number two is that the prices had risen, a brand new company that's going to go nationwide that started in Tallahassee on the day the jet started. And the reason why they were able to start is because the price is so high; it's like a private jet service that would fly throughout the region but starting in Tallahassee. And they were able to do that because basically the prices have gone up close to first class.

Mark Frisse:  The prices have gone up about to make an entrance coming up with a dramatic different model. Have you read the book called the "Innovator's Dilemma"? I got quite pressed on it. It's a book that basically says the guys that built the steam shuttles knew all about the back hole. They knew all about the back hole but they said, "Hey, there's no problem in the back hole, a little dingy thing, I can make a bigger steam shuttle, that's what I'm good at."

The guy did build a big disc drive knew how to make a smaller disc drive better than anybody else. But they had better margins by building that disc drive bigger and faster than what they did. The people who built computers knew about personal computers and laptops, the AVR were never dead in the equipment corporation, obsolete companies so popular in the 80's. He said the PC is not going to make it anymore.

Every organization has a certain structure to it and optimizes that structure. And guess what? The marginal profit is always better to extend slightly to prove a thing that may no longer fit the market than it is to break free. So, the only people that usually innovate are the Apple computers of the world is the back hole people. These are the people with no other options.

The dynamo and electric motor, in 1886 the electric motor - it's classification scheme, in 1886. Do you know how long it was until 50% of the machines in America's factories were run by electricity and not steam or by water? 1922. Almost 40 years, because there were standards wars; Alternating current with Nicolas Tesla; direct current, Thomas Edison; an icon, probably everyone knows about that..

All kinds of things like that, standards wars. And the guy will come in to the CFO and say, "Hey, I will try this electric motors CFO's. What we've got perfectly good poles and steam shuttles left. The ROI is going to be just add another pole." Okay, boss, whatever you say. They're the only people who don't have anything else to move electricity.

So, innovation, when you think about airlines, innovation is going to be the only way out for them, too, right? If you've heard about the little personal checks? They're using cruise missile check engines now and the companies go to jets basically only hold three or four people. And if one actually fails, a parachute comes out and it lands. The jet is not usable again in your life. And there's a whole bunch of people out there, books written about it, thinking about personal air taxis that we might get to that point in terms of price margins where something that dramatic is going to happen.

Let's move on to quality for a minute. We talked about quality. I want to show you what people have been doing. We've talked about what people are most likely to be doing. And that’s' -- okay, go one more. Two options, right? Southwest airlines, one price it's own. So, I can just find it, transparent, those tickets make sense. You know exactly what you're getting there.  

But a lot of you, would you fly Southwest airlines if you had a choice? If it's free, do you have a choice between South Air and West airlines and something else? You're not going to Southwest. I don't know about you, but I love my upgrades. I'm an American Airlines gu.

Each of us has a preference. So, if I wanted to go now on the preference on the next slide, go to the preference, they're also not giving me this complexity. I can't escape it. So, the real question is, is there anything in between? Can I have the simplicity of Southwest Airlines with a few minimal choices? Do I have to always stop in between to do it?

I want to show you just real fast, sites that are out there. You probably know what I'm thinking about. There are sites that basically gained the system. Farecast is one, keep going. Farecast would tell you exactly what the right day is to buy a ticket to what town. Will found one for a guy that just does nothing but track Northwest Airlines flights out of Minneapolis St. Paul and it tells you how to gain. He's got an issue with Northwest Airlines. Every time they try to come up with some new complex pricing, he comes out and say, "Get it on this day. Do this. Go online and get extra points." He just sits there.

And so, you get these consumer groups kind of looking into doing price, okay keep going. So, they actually do statistical predictions of when the right price is, when the right day to fly. You know, we have all these tools that has to page airlines but you don't really know, okay, I know if I'm flexible about my days I'll get it but you don't really know exactly how much. These sites actually take all the stuff, they pull it out of these other sites and then they actually plot it out to tell you the right day. They give you the optimum.

So, instead of just saying, "I'm going to play round until I find the right price I like," they'll tell you the optimum price. Cardiac is another one; I don’t know why they call it cardiac. But again, the difference between the best fares and the average fare is pretty good. And of course, you get this $200 for these flights; at least if you're familiar with your trip, you know a lot of us can take a dollar from these flights. Go on

What about quality? They kind of imply a little bit about price quality. Do you want quality out of your airline? Is that worth something to you? What does it mean to you?

Participant 7: Quality is integration really involving multiple factors, multiple variables. It may be wait time, it may be to get back in to the plane, to get off the plane, maybe how you are spoken to by the airport's desk or person that is doing that, it may be how much leg room I have, it may be whether I'm given snacks or not, but it's a lot whether I'm warm or cold, whether the lighting is good. All of those things come together to determine an overall impression of quality for me.

Mark Frisse:  Okay. And how about somebody else? What else?

Participant 6: To keeping you safe.

Mark Frisse:  Staying alive.

Participant 6: That's number one.

Mark Frisse: If the airline have to land on a different airport, "Well, it was always raining in there that’s' why we landed here. I hope you don't mind." What else, what other quality issues?

Participant 5: Customer service.

Mark Frisse:  Customer service. Okay. During the flight, before the flight. How about what you paid at canceled flights? I mean, I fly a lot, and if you cancel flights it is non-refundable. Doesn't that stink?

Participant 2:  Like you said, you're on your own and what was your question?

Mark Frisse: What else about quality? Do you know how to find quality in an airport? How do you find out?
You ask a friend? Personal experience? How do you find it out?

Participant 1: Personal response, personal experience.

Mark Frisse:  Personal experience? Kind of like choosing a health care, huh? So, they say. It turns out there are all kinds of sites out there for quality, for airlines. This one is called Seat Guru. It's a front end of all your night plan, whatever. It tells you where the outlets are, what the meals are, pick a flight, they'll tell you to avoid this road and shorten the seats.

Some of these are done by people online contributing continually and then they edit. So, there's nothing like, sometimes real-time, like when you hold the quality questionnaire, please tell us your experience at our health care facility, whatever. These are done real-time, collected somewhere, somebody just puts them up there and some of them are like blogs and they just put there and they rant and rave and there's some signal and there's noise. But they're out there. They're out there for airline quality.

Here's a table that kind of basically shows you all the kinds of scoring, seats this, stay with this-- I don't know if you know, some people are like really in the detail. They must be like eight engineers who really care about that. And these are a whole bunch of them but they create a couple of sites.

One is, you have quality sites that are by a status organization. There is a university-affiliated group that does all kinds of things for publicly available data, pulls it in from different sites, creates a site that basically tells you how much they are on time, what their near misradius, kind of safety things you want. There's the equipment like a J-codes for airlines. Right here is a JD power survey in sites.

And then all these people were people in communities, just getting together and come up with a bump tracker, how to get bumped. Some of them don’t just warn you about getting bumped; they'll tell you how to get on a flight so you'll get bumped, so you'll get a free ticket. So, what's the point of this?

The point of this is, forward I think, one, you can have a simple system where the rules are very, very simple. Or you can have a very complex system and as soon as you start introducing a lot of choices and preferences and you do something else than that, then you get into the complexity business. And decision number one is whether or not you want to be in the complexity business at all.

But if you do want to be in the complexity business, you've got in about a third of our health care dollars that was actually going into that complexity business. At least, most of our time is in managing this complexity, right? If you want to be in that business, how do you do it in the way that maximizes the choices people make, that are meaningful choices and lowers cost? You don’t want to spend all of your time, I mean, Governor Curtis sent this to me, he said, "What could the internet have been like have the travel agency designed it?"

I suspect it would’ve been a wonderful, secure, solid internet. Wouldn’t we have all the markets stock? I believe so. In other words, if you basically don’t start with version 1.0, a little simple kernel, this activity, this is not a cotton plant. We're trying to work this problem in the airline field just like we're trying to work in the health care.

So, the point is, I think you've got to figure out, if you’re going to be in the complexity business, what that means. And you have to understand that most of the disperses you have right now were the result of historical improvements. Everything that was done in the airlines industry was done and was making sense at that time; but now we're displaced. The worst disease in health care, I believe, is something called hardening of the categories. They have pitted us against one another.

Michael Porter says, "Like Gandhi said, 'What do you think of Western civilization?' and Mahatma Gandhi said, 'I think it will be a good idea'.  If people said, "What do you think about competition in health care?" You ought to say, "I think it would be a good idea." Because Michael Porter would say we compete, we compete like men, those in this room, then most of you had to compete but are you competing over the right things.

And what we're going to try to do over the next few days is to figure out if this transparency is going to be a means to an end for the healthcare authority. It's probably going to go to other things.

Participant 7: And I think one of the interesting, the other interesting things about this is that there are sites out there that just focus on some things like quality. And there are sites that focus on price. And I think if we look at what the values to people is, I would say, this is an anecdotal statement, that people more would go to the price websites.

Now, it would be great if those price websites also included things about the quality. So, there's something, I'm not sure what, but there's something that says about the value of different sites and perhaps also looking at it from a consumers perspective of what really will draw the consumer in to look at them.

Participant 10: Just to compare, Delta Airlines have to be my preferred airline. And they've gotten to the point where they tried to incorporate this much data to you as they would, as they're willing, to help do away going to other sites. They tell you the preferred seats; they tell you the size of the seat depending on the airplane you’re flying. They tell you how often they are late. So, it seems to me what they’ve done is tried to import, tried to use their own data enough to keep you aligned with all the booking in that side.

Mark Frisse:  So, it clicked.

Kim: Yeah, I think it’s real interesting that we saw a bunch of different websites here for airlines. And for health care, we've got a bunch of different websites, and I don't with the airlines sites because I'm not familiar with it, if they all say the same thing, I would suspect that they don't.

And if we look at the health care websites, they don't say the same things. If you look at the data on, if I go to my health plan website, I see something different than what I do on computer care which is different in what will work for you. So, it’s very confusing for a consumer. And maybe with airlines it’s okay because it's not life and death, necessarily.

Participant 1: It’s always life and death.

Kim: With health care, it could be. You choose the wrong place to have your open heart surgery; it could be life or death. And, yes with the airlines, I think the extreme is you choose the wrong airline and you have a crash and then…

Participant 5: It's not personal. You’re health is very personal.

Mark Frisse: Let me push you on that. So, what you’re saying is if there was an airline that it was a matter of life or death, that airline would not exist.

Kim: Right.

Mark Frisse:  So, how come we allow our hospitals to exist if it's a matter of life or death? It bothered me that you say it may exist. Why do we operate that?

Kim: Is it the hospital or the organization?

Mark Frisse:  I don't know. I just mentioned hospital but the organization -- whatever you're choosing. I mean, why do we allow that? Why do we not allow that? I mean, you wouldn't let -- I mean, a pilot makes headline if they drink and don’t make up, right? Why do we allow it?

Participant 1: It’s not all of them. I mean, the proportion of pilots who drink vs. the proportion of pilots that make headlines, they're significantly different. And not everyone who dies in an institution ought to have lived.

Mark Frisse:  Yeah. I think sick people tend to be in hospitals more than healthy people, we hope, and they tend to die more than healthy people. But those are the kind of things we want to debate without getting back into the issues. But you see, you say life or death, and a lot of it is not life or death. I mean, that's --

Kim: I think it’s the complexity of health care. And I feel one more here. And I needed some type of procedure; I don’t know that I can figure out what to do. And I probably would call one of some of the physicians that I know and say, "Help me figure this out."

Then you look at the average person, and I think that's weird figuring out learning to know your health care data. You've got to get to that clinic so that we can help and the person who needs care and need to have some understanding and start the basics and the websites that are available don't start there.

Participant 6: Actually I agree with what Kim was saying. Because what I hear from you more than which hospital just should be in business or shouldn't be in business, is this need for a trusted source of the right information that everybody is as well coded. If you think about the airline industry, for example, I mean this is not a great example, Orbitz or Travelocity, those have emerged out of the multiple, gazillion different discount sites as ones that people generally trust.

I guess they say it was objective because they're going to put your rate in there, it doesn’t matter if you’re Delta or -- they'll put your weight the way it is, you fend for yourself. And if one of those trusted sites also had, for example, quality of seats and meals and whatever, I think people will be more likely to trust that and go there and trust what they are saying.

So, in health care, you’re right, there are various trusted sites but even those sites don’t put everything together at the same time. So, you go to WebMD for the Medmill pharmacy medication or quality of care and you go to the State for pricing. So, I'm going to agree that getting a trusted place is important.

Participant 7: I think Kim brings various points but I think that even a worse solutions that come on to us, these are the websites that exists with different performance standards. Standard quality of care and the fragment of what the recording on each doctor therefore if what is belittling was not in the index of that performance.

And they say not only do they have your performance measured but I would never probably go to the website to check. I would like go into that to go to New York and say, "Hey, I'm just trying to do a good job on this." Because I trust that board to see if these people are working, I'm not sure I'll trust these websites.

One of the things that I would only come is if there is some way that, you know, all these information that's out there that has questionable value, to standardize it and to bring in together, because as long as it is fragmented it is of a very low value. And you can look me up on one man's care, I'm a terrible doctor and on the other one I'm the best doctor they had. And I'm the same doctor just different set of performance methods for different set of patients.

Moderator:  Mark, a couple of more questions.

Participant 1: I guess, this might take some of what's said, but when we talk about trusting source, if you will, and none of them are in the care industry, but just looking at any other industry, when I'm looking for a computer in two years, I don’t see any reports that is a trusted site, I feel I could just find out about this new vitamin product, what's the value, how is it rated. And then, I could, by getting a good price for that value from that trusted site, from that trusted source. I don’t know if we can do that in health care and then another is to look at trusted source can compare, would you know about the product to the  value?

Mark Frisse:  One more question.

Participant 4: One of the articles that we had on the libertarian paternalism mentioned, gave an example of somebody going to France to a very fancy French restaurant and had an unbelievable number of choices on the menu but not really understanding the French food. And the way the French would handle the tourists is to limit it and bring it down to a tourist menu that is easily understandable and quite frankly that makes the tourist happy.

And in terms of health care, which is very complex, I think at times we fail in relation to the health care people that we know what to give consumers in terms of all these various choices. But frankly, we can really have to understand what the consumers can digest. And then allow them at some point to go or later down what's been scheduled.

Mark Frisse:  You’re right. That's a great detailing.

Participant 7: I just wanted to make sure that something wasn't lost here today. We talked about the consumer but we all, I think, need to understand that this communication is as much directed to the providers that it is a great portion of what we have to figure out how do we communicate those value to the different prices, not necessarily the same. All you want to know is what you paid for. So, I just wanted to highlight that.

Tom Lloyd: I also like to just, from listening to the conversation, it's very interesting that you have a language that you’re using and at some point will allow them to go in. And the people that are driving the airlines crazy aren’t being allowed to do stuff. They are saying, "Bad word, bad word you, I'm going to screw your system. I'm not going to let you treat me like a child and only allow me to sit on this table until I've proven to you that somehow I'm capable of getting it."

You look at the world in which we live, I think you need to strategically think about your role as a provider of information that other people can use. They can trust that what you provide them is right, true and good. But how they use it is up to them. And you’re going to have to separate part of those things as you move forward.

People just don't care what you think. Honestly, consumers, they don't care about these things. They care that I'm sick and I don't understand why you can't tell me when I go to you, right? The great thing about airlines is you know it's a price and that maybe the only thing you need to know. But you know you're going from point A to point B.

And so, a lot of the work around, I think transparency is going to be defining what is point A and what is point B. And because of the way health care is, what does that mean? What are the top 100, top 10 evidence-based practices that we could provide everybody and say tell us how much you would charge to do this. Right?

And then we can start having a conversation like this. We can't have this conversation as long as we're all at, "Well, you know, you could've put that one." And those are some of the things that, I think, this group needs to get to. You need to start thinking about the consumer and really wearing that hat.

Participant 8: We have a part that brought us here. It seems to me that in this country, we have an issue we will call health care illiteracy. And so, you’re now asking the consumer to go to websites and then get back on even though they don’t know how to get to one to see what quality is like. And so, how do we get to cash in that possibility? Because they deserve the same, they need that same information.

Mark Frisse:  Store that energy up because just in a few minutes you're going to be going down and you’re going to be able to make those points. I don’t know if we could make one more.

Participant 9:  I just like they can give permission to create these different websites.

Participant 8:  As consumers, we have the permission and I might already be the opposite which is the number of university and the competition between and among the information sources is just as important. The media ask me all the time about this and my answer is, "Of course we want to inform consumers. We just don’t want it to be handed by a single source of information. We want them to still ask their doctor or to look at the newspaper or read the report in addition to 40 new websites." It may be confusing, but the diversity is not necessarily a bad thing.

Mark Frisse:  That's going to be a conversation, I think, we're going to keep having. One more final slide then we're done. You mentioned the bar space. First of all, Delta airlines had said, "We're not going to compete by hiding information from you." can you imagine an airline company, "What am I going to say if call somebody?" I'll say you go ahead and trust him.

Do we have the right stuff to begin with to make a decision? What Dr. Okinobi wants the same thing is what Kim wants and do we have the right information? If we have the right information, can we take it all and put it into something that is understandable in the sense of representing it in a machine? Keeping it updated or organizes it manually or whatever. That if we get that stuff that's in a meaningful quality metric, so we'd say this is the metric: plane crash, N people died, that's pretty good metrics, you know, surgery deaths, that's good. Can we get meaningful metrics?

And if we have the metrics, somebody said here, does that mean we’re going to understand it? And even if we understand it, here's a fact, smoking is not good for you. Trust me, I have a website on that. And would you change your behavior?

In order for this to work, all of these things have to be getting better. And look at the airline industry, these guys are good. Their stops are point A and point B, you know, it’s finite. Here, it's different. We're negotiating different price between the baggage handlers and the pilots and the flight attendants and the TSA, we have so many faction inside point A and point B if you even know where it is. That it's a complex system of arguments more than anything else and all kinds of other stuff. It's so hard to get your hand around.

We want to be using airlines as an example, primarily, because we wanted to help you understand that you have to go a little easy on yourself. That this is very, very difficult. It is not even clear how far you can push it, how far you can make it informing the consumer. But we do know, I think we all share the belief, if we don't find out the way to weave out of this and head in that direction, we're not going to get anywhere.

So, we're going to be talking a lot, one of the specific charges is integrating the website, integrating the design. But you'll understand, as we're disagreeing about some of those things, it's not about the website. It's about do we have the right information that we're collecting? Are we representing a meaningful, consistent ways about the different enterprise? Are we going to make it some way that our consumers and all of us can understand at a point we need to make a choice? And finally, will it change my choice? Will it change my behavior? Yes?

Participant 1: I think the other issue that we have to deal with is some of our facility in hospital site, 70% of our admissions they come from the ER, so at what point is that page is going to go website or whether they are going to go. They'll probably not. But there are not a very high percentage of admissions in hospitals that come through the ED and that seems to be rising.

Mark Frisse:  Yes. And we can talk offline or before the later breakouts about systems and care and why that happens and what can be done about that. Yes, that's what we can do. So, we'll end it with that. But does that make kind of a sense? I mean, I just want to let you know that what you’re doing is very, very difficult, there are differences of opinion. And you don't have to be in the health care business to basically be in one of these things and really start getting along down.

Moderator: Thank you very much

[Applause]

Peter: So you will all be presenting up here and you will learn that I am the substitute for the Oscar music. So when you see me do what I did to Mark, you know this whole thing. It means time is ticking.

[Laughter]

Peter: That's my role today. This is the last time that we're going to present to you. I can tell from the conversation you're ready to share ideas. So we're going to transition into our first activity. This is our first attempt to be collaborative, alright. So this is what we call "Take a Panel". These are panels that we have shipped in and these are whiteboard panels. And everybody is going to get a chance to compose their view, their individual perspective of where we are and where we should go. Okay, we have assignments that Steven and Lea are handing out.

But I'm just going to feedback to you some of the big words that Dr. Mark shared with you because we're going to dig underneath those words. And figure out from each of the perspectives, from the patient, the payer, the provider, the insurers, the hospitals, the doctors. What these words mean in reality? Complexity, choice, timing, market, accountability, value, volume, regulation, optimization, quality, price, transparency and trust. Okay. We have about 30 minutes for this. Please move as quickly as possible and Tom has one thing.

Tom: So one of the things we did just want to point out is Tennessee is not a sunshine state but it does not mean we're not happy people. So the whole dynamic of having people in the back who aren't getting assignments, it's just very weird for our team just know that. I'm feeling I just need to say, we recognize you're here and you've taken the energy to come and we are so appreciative of that.

We do have ways for you to feed in information into our process but when it comes to actually the modules and doing this break out work, this is the time for the invited participants to be providing their perspective. So we're excluding you for a reason if you will, alright? And just know that and we'll move forward.

Peter: Alright. Thank you all and in 30 minutes we will see your next assignment.

Speaker: So we'll break out into groups.

Peter: Stand up and scatter like cockroaches when the kitchen light comes on.