. Page 1 . >>ELIZABETH MAJESTIC Good afternoon. Good afternoon. Thank you. My name is Elizabeth Majestic. I'd like to welcome you back from lunch. Including the free entertainment we provided. I hope you enjoyed your lunch and the entertainment. We have a lot to do this afternoon. We have some terrific speakers and you want to go ahead and get us started and talk a little bit about what's going to be coming up next. Before I do that though I'd like to take care of one housekeeping detail. We have several women attending the conference who need rooms for patient purposes. I would like to let you know the Heron Room on the fourth floor is available for the purpose. If you have any questions -- (Applause) Thank you. If you have any questions, contact any of the contract staff in the blue shirt and they can make sure they direct you to the Heron Room. Okay. We do have a very exciting afternoon in front of us. And I want to start that off by introducing to you Mr. Michelson who is the Chief Executive Officer and President of the Prostate Cancer Foundation. He brings strong leadership and over 20 years of healthcare experience to the foundation having served as founder, C.E.O., investor, advisor and director for portfolio of entrepreneurial healthcare real estate companies. After practicing law in Washington D.C. Mr. . Page 2 . Michelson was recruited to become the special assistant to the general council of Department of Health and Human Services during the Carter administration. He then joined a private equity investment firm focused on healthcare and real estate investment. In 1988 he co founded and became Chairman of the Board of Value Science Sense Inc. He then co founded -- Chairman of the Board and C.E.O. of proto-care, provider of clinical trials, site and disease services for pharmaceutical services. He became C.E.O. of Acarion who recruits patients and physicians for clinical trials. Please join me in welcoming Mr. Michelson. (Applause) >> MR. MICHELSON I always dread being the first speaker after lunch because the lunch requires us typically to take a nap. 715 calories for most of us, I guess that's just a snack. My job after the lunch entertainment I had no idea there would be entertainment during lunch. My job after lunch entertainment is to speak to you. Your job is to listen to me. You could help me do my job if when you're done listening put your heads down and I'll know to stop talking, I'd be appreciative. Wasn't that a terrific presentation from the secretary? I mean lets have another round of applause. (Applause) Wasn't that just great? That is a man who has passion, focus, made a . Page 3 . difference and going to continue to make a difference. I am very enthusiastic about that. I've done a lot in the healthcare business over the past 20 years. Healthcare business defined to include the political side. Been in managed care industry, been in the government. Done a lot of different things and reflect about what it all means. And I thought since you all really know much more about prevention than I do or ever could, that I just try put it in the context we use when think about some of these issues. Look at it from the long range of history and ask the question, what is the most significant accomplishment, what are the most significant accomplishments of the twentieth century, I think you'll come up with a lot of healthcare related things. (Applause) And I think when the history is ultimately written, the first paragraph I think we'll talk about the extension of the human life span by over 40%. In 100 years for species depending how you count, has been around for 100,000, 200,000, maybe 300,000 or 400,000 years. To have the kind of increase in life span has to be the first paragraph of any history. And it is really because of number of things. Been terrific progress made on sanitation and hygiene, vaccinations, infant mortality has dropped dramatically. First half of the century. In United States in particular as was discussed earlier in day, and I won't go into the detail, there's been . Page 4 . tremendous progress made on cardiovascular disease, which is the one of the leading killers. When we look, I think there will be symbols of things that happened that truly changed the world. (Applause) Little bit before I was born, not quite as much as before I was born as I would like to think at times. 1952 in which polio declared epidemic with 58,000 cases. Epidemic and people forget, only 1200 deaths that year but kind of intense focus in which America is at its best when all the resources of the country are focused on one problem. It wasn't too many years later that figured out to distribute the vaccine. One of my people of the '50s, Elvis. That's actually a real Elvis was getting his vaccine. And by the next year polio was almost gone. I think that is an image that all of us have progress made in battling a particular disease. There are other successes. For example, childhood leukemia used to be a death sentence. Very few children diagnosed with leukemia would get to see four or five years after that. And today tremendous progress over 80% are cured and each and every day it is getting better. The model of the 20th Century. We're now in the 21st Century. One of the people who I am very fortunate to get to work with in addition to Mike Milkin. One of the many books written, only paranoid survive I think since I am so paranoid I . Page 5 . would do so better -- excuse me. Okay. Who got that joke in all right. Would you give me your card? What Andy observed is things typically go long and aligned for a while and there's what's called the point of inflection. Point of inflection where some change makes it impossible to continue on that line. That line doesn't exist anymore. And what exists is another line for people who understand the change and another line for people who don't. If you really attentive to what's going on and you understand the changes and you change your policies, change your company, change your business, change your program, based on the fundamental changes in technology, economics, science, society, ethics, religion, whatever it might be, you would exceed and accomplish in your goals and north on the symbolic chart. You don't you will go south. The point I want to make to you today is that I believe that we are here today at that point of inflexion. And let me see if I can make the argument with you and see if you agree. Fundamentally new challenges we have never seen before. Because as result of success of all those initiatives of antibiotics and hygiene and sanitation and treatment of cardiovascular disease, we're living longer and as we live longer we get diseases we didn't have because they typically don't kick in until we're older. There's no disease for which that is true for . Page 6 . prostate cancer. And I am very proud to be the C.E.O. and Vice Chairman of the Prostate Cancer Foundation, largest foundation in the world funding research on finding better cures and treatment -- better treatments and cure for this terrible disease. What you see here -- I don't know if curried it from back there. Is there a specific likelihood of getting prostate cancer. I've been studying healthcare statistics for decades and never seen the line that looks like that. This is disease lies low until men turn 50. They turn 50, 55, 60, it kicks in like rocket ship going off. I finally saw the data, I said to myself, what else looks like that curve? What else looks like that curve? And then after about three days of thinking about it, I was given a slow chip. Finally realized the other thing that looks like that curve is the baby boomers. We know the population demographics, know the age cohorts of men in the country. As the baby boomer population, every one of the lines represents decade of how the baby boomers get into the target zone for prostate cancer and epidemiologists do the anal sifts. Very steep curve, what you end up with very troubling number of statistics. First is not only is prostate cancer the most common cancer in America, most common non-skin cancer in America today. Few people realize that. It is also the one with, you know, isn't to the limitations of any epidemiological . Page 7 . study is the one that's going to have the greatest increase in incidence over the next ten years as the baby boomer men get into the target zone. Rather than having 220 cases we have -- 220,000 cases which we have today, over 300,000 cases coming up. I'm not sure any other industry have certainty until growth. That's very troubling for me and my colleagues. Even more troubling is this which results -- which gives you projected death rate of breast and prostate cancer. Breast cancer is a terrible disease. We're losing 40,000 women a year in the United States to breast cancer. Losing 30,000 men a year now. Decade we'll be losing more than 50,000 men a year. To put it in some context, in the Vietnam War, in the 20 years Vietnam War was fought, we lost 50,000 American men. Every year now from prostate cancer alone we're going to be losing as many men as we lost in the Vietnam War. Again, just to put in context so you can appreciate how significant the demographic trends are, we remember the terrible, awful unthinkable month of September 2001. Tragedy when terrorism hit shores of the United States for the first time. Awful, awful event. In that month we lost more men to prostate cancer than we did to terrorism. The month before and the month after and every single month since. That's a big problem that people don't realize significance of. A problem that . Page 8 . we need to deal with. So that to me is results and point of inflection. Result -- another reason point of inflection here we have all discussed for the morning and I won't go into all the detail, we now are seeing as American life-style continues to evolve in ways that are unhelpful, having a very sharp increase in the life-style induced diseases. Know the data as well as I do. Fully 70% of healthcare spending is on life-style related diseases. Drinking we all know about. Smoking we all know about. Obesity is something we're all learning about. Lots of different ways to talk about it. It all comes down to the same point. Usually use English language. Occasionally I make up words. Here is a word I hope everybody will take home with them. What do you think? Stand the test of time? I think we have obesegenic society and I think we need to do something about that. All right? It is not just a simple problem. It is one that has huge consequences and we as a society as secretary said in different words earlier today, need to stand up against that and stop ourselves from being obesegenic society. Obesity increases complications of or likelihood of. Sometimes it is useful to look at it from other perspectives. Somebody is playing with my computer. I'm sorry. 25% of the children are now overweight. We have a huge increase in that. And we . Page 9 . are not begun to see the healthcare costs associated with the kids. Socioeconomic and other costs associated with that. So I have got a question for people in the audience. I actually have a prize for the winner. In the '60s order of McDonald's french fries -- some may be too young. Contained fewer than 250 calories. How many calories are in supersize fries today? >>AUDIENCE (off mic) >> MR. MICHELSON Who thinks it is 525? I have health experts here. Thinks it is 610? Who thinks it is 1,025? Let's see who is right? 610 calories. Just came from a lunch. I took the menu with me to show my wife. She won't believe I was there. I had to take something. 710 calories for delightful lunch and one bag of french fries 610 calories. Have obesegenic society. We need to do something about it. Take soft drinks. We had 1950 -- eight ounce Coca Cola. The industry standard. You couldn't get more than 8-ounces of Coca Cola no matter how much money you had and what you wanted to do. Now get 44-ounces. Okay? Lets just take another friend of ours, old hamburger. I don't have the calorie count because there weren't enough digits on the computer to put it in. Are plus, minus true to size. Good old days. Now you can . Page 10 . have $6.6 million-calorie guacamole bacon cheeseburger. We got obesegenic society and need to do something about it. Touch on political hot buttons and if I do -- apologize. Don't apologize. If I anger people, lets talk later. I think it is unacceptable that one in five schools sells fast food that has very low nutritional value to kids in lunch. Only taking them fat but training them to do the wrong things. Vending machines on the present schools have the wrong things in them. Thank you. May be stepping on some toes and making people angry but we as society have to stop that. We have got government funded hot lunch programs. Only 20% of them are within the U.S.D.A. fat limits. (Applause) Stop it. Come on. We together can figure out how to stop that. Have to do better. And if you look at the rate of increase of foods in ten short years each on per capita basis, 18% fat even eating. In 140-pound of extra food each year. We live in obesegenic society and we need to stop it. Physical activity. I was stunned this morning. I had a conversation with the secretary about it and he was surprised as well when there was such strong support from all of you when he mentioned putting physical education back into education. Striking that less than 1/3 of the kids in high school have P.E. as in their regular program. This is a group that has to change that. We . Page 11 . have Pepsi here. Pepsi is good but they really decided they're going to take a leadership position here and make a difference. Now we have committed $200,000 to support this program. I'm going to embarrass Galan if she's here. Anyone think Coke should match it? (Applause) We live in a democracy. Problem -- and you're familiar with those. I want to talk about the cost issues as well. Studied the cost issues for 20 years. New place in the healthcare cost issues and one of the things results having point of inflection 14% of the G.D.P. on healthcare, going up at 4% year on current state of the economy. That is predicted to go between 19 and 25% of the G.D.P. and to healthcare services. Cannot sustain having everybody work Monday and of Tuesday just to take care of the healthcare services that are result of the bad food, bad life-style that they had as a result of that. That is unprecedented. People say well, we'll figure out solutions to it. Is where it is really changed. Okay? What this shows you, it is a complex, percentage difference 4% trim line over 3 and occasionally been able to dip below but only stays for a little while and run out of steam. First thing we try people hardly remember in the Nixon years there were actually wage and price controls, Republican administration had wage and price controls in our lifetimes on health. Worked for a little while and then . Page 12 . ran out of steam and was counter productive. Next thing we tried was national health planning. Worked for a little while and ran out of steam. Next thing tried was halfway competitive markets and ineffective regulation. Clearly disaster. Then said lets do it American way and have managed care. Have fully sort of commercial competitive environment. For a little while and run out of steam. I don't believe that there is anyway to contain the rapid run away increases in healthcare costs without focusing on prevention. And we got to do it. Thank you. A problem. Costs more now than it ever cost to develop new drugs. There are a lot of reasons for that. But it used to cost in 1976, which was a couple years before I started working the government healthcare issues, it was $54 million to bring new drug to market. Now, it is $802 million. That is a very different proposition. Used to take about eight years to bring a drug to market. It is now 14 years. That's a very long time. And even with the extraordinary developments in science from decoding of the human genome and chemistry and prodomics and 3D crystallization. Still having fewer new drugs getting through the F.D.A.. What's happened is we taken the low hanging fruit which we have eaten it. Taken the low hanging fruit and figured out how to solve the diseases. These are tough diseases now. Have to use prevention, . Page 13 . can't use treatment alone. Last issue is the decoding of the human genome will result in highly individualized treatments. Different things going to take some time to work through. One of my favorite quotes from Albert Einstein, one of the smartest people of the century, requires greater intelligence to solve the problem than it took to reach the problem. Okay. That's why we're having problems in our new drug discovery. But that's what we need to do now. This is going to be harder than getting here. So here is a couple things that we're working on so you can get a play -- don't analyze it we attack it. Have enhanced education technology for kids. Anybody who has a kid in the third or fifth grade and comes you I'll give you a leap pad. 30 or 40-dollar toy technology has the capability for kids to learn. Very simply and learn about skeleton, learn about digestion, learn about nutrition and learn about their bodies. I got a gift anybody has a child and would like it, because that way I don't have to carry it home. Second thing we have done is company that uses the internet to support adults who are interested in life-style changes. Have got a program called Mia of Eat It (sp), to get diet and exercise stuff. We have written couple cookbooks. They aren't the regular cookbooks. What they do is take the favorite meals, favorite dishes and figure out how to convert them . Page 14 . they're helpful with far fewer calories and less fat so you can't tell the difference. We have done this in a variety of context substituting in lunchrooms, having dinners where people can't tell the difference. If you take away some of the visual cues and dupe them enough, they start eating this stuff. Tastes just as good. More seconds. They're going to shoe me off the stage. We have done a lot of research on nutrition across the country and around the world. Beginning to work closely with the Heinz Company. They're one of the major producers of cooked tomato products and what we have learned from nutrition research is cooked tomato products seem to have effective test against prostate cancer. F.D.A. introduced program easier to get qualified food claims without having to go through definitive scientific work you sometimes have to but get new information out to people more quickly and I think that's going to make a big difference in helping the food companies rally behind this cause that we all support at having healthier cuisine. Looking at much tighter linkages between the genome, we're studying the epidemiologic implications of disease and health promotion. For example, question I always ask myself, because we have a system in this country, health insurance premiums -- I'll be done in one second. Okay. You can come and team with me. All right. . Page 15 . Health insurance premiums are tax deductible. Don't you think it would make sense that training for nutrition and better life-styles should be tax deductible as well? Seems to me go back. I'm with you 100%. So with that I want to have one last comment. Been a time to reflect who we are as Americans and what we do and stand for and why it is important. I think a lot about these issues. To me what America stands for is the capacity to take a good idea and make it a reality. That's what the world saw in the past month. Hopefully going to see a lot more of it in the next month. To me there is no idea better than the idea that genesis for this conference. Make prevention our mission. And America is a country that can do that. And I sure hope you people are leaders to make that a reality today. Thank for you the time. I apologize for overstaying my welcome. Thank you. (Applause) >>FEMALE SPEAKER Thank you, Leslie, for sharing your thoughts with us and becoming part of our group that it is going to be pushing for prevention. Want to step back for just a moment and talk a little bit about a document that is available to all of you and it was a document that Secretary Thompson was supposed to have released over lunch, but in his excitement and passion about prevention he forgot to talk about the document. I'm going to take just a couple of . Page 16 . minutes and highlight a series of three documents that we call the prevention portfolio. And the prevention portfolio contains a document called the power of prevention. This document is really designed to help policy and decision makers grasp in five to six pages why we as a nation need to invest in prevention. Talks about the health burden. It talks about the economic burden, it talks that prevention works and gives very good examples about why prevention works and why we think this is the right course for the nation. There's a second document in the prevention portfolio that we call prevention strategies. And I heard many of you talk and congratulate the Secretary earlier in the day. Prevention strategies document that really contains the evidence base. And again, we have put this together with the expressed purpose of helping policy and decision makers not recreate the wheel but having a document that tells them what they can do. Finally in the prevention portfolio is a document that we call prevention programs in action. Prevention programs in action is really about you. It is about the good work that you are already doing out there in states and communities across the nation. We have attempted to do at H.H.S. is to capture some of those exemplary programs that are out there. And we hope that these examples will inspire the leadership of policy . Page 17 . and decision makers to see that in fact it is going on and that there's some great examples perhaps that could be adapted in their own states and their own communities. This document will be available and I think you can get it at one of the displays outside the ballroom. So I encourage you to pick up a copy of it. Now it gives me great pleasure to introduce one of my favorite colleagues in the department. His name is Dr. Howard Zucker. And Howard is the Deputy Assistant Secretary for Health for the U.S. Department of Health and Human Services. Howard is going to be talking about diabetes along with several colleagues that I've had the pleasure to work with over the last several months. But he's going to introduce those colleagues. I want to share a little bit about Howard, because he's truly one of the gems that we have in the department. Howard Alan Zucker is Deputy Assistant Secretary for Health at the U.S. Department of Health and Human Services. Most recently he was the White House for the Secretary of Health And Human Services Tommy G. Thompson and has been actively involved with genetics, tissue engineering, bioterrorism, public health preparedness, preventative health strategies, xenotransplantation, bioethics, international health initiatives, healthcare reform and formation of Medical . Page 18 . Reserve Corps. He received his B.S. degree from McGill University and M.D. from George Washington University School Of Medicine. Served on Yale School Of Medicine, Columbia University College of Physicians and Surgeons and Cornell College of Medicine, Academic Facilities and Center for Space Research at Massachusetts Institute Of Technology. Dr. Zucker maintains his clinical skills as member of the clinical faculty at National Institutes Of Health. He also holds a J.D. from Fordham University School of Law and L.L.M. from Columbia Law school focused on genetic engineering and public policy. If that isn't enough, Howard is the real life Doogie Houser. The gentleman they based the television series on. Howard, come on up here and tell us what we're going to be doing here on diabetes. (Applause) >>HOWARD ZUCKER, M.D. Thank you. Clarify one point there. Last point. All the other is correct. Probably a lot of people -- they just speak to me and how much and who else they spoke to, I don't know. Just to keep the record straight. It is great pleasure to be here at Secretary Thompson's Prevention Summit. I thank the Secretary for the opportunity to share in remarkable two day event that highlights all the reasons why we must incorporate prevention into the . Page 19 . future of healthcare delivery. I have been asked to moderate the session on Partners in Public Health working together. And I am privileged to share the stage with three super stars in the field of preventative health and diabetes. Allen Spiegel, Director of National Institutes of Diabetes and Digestive and Kidney Diseases at N.I.H. Frank Vinicor is Director at Division Of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion and C.D.C. We will first hear from Dr. Vinicor and then Dr. Feetham and then myself and then Dr. Spiegel and Dr. Vinicor will summarize with couple things at the end. Thank you. >>DR. FRANK VINICOR Hi. To find out how to advance -- there we go. T.J. is a 46-year-old divorced mother of three children with 11 year history of type two diabetes. She is being treated with oral hypoglycemic agents. She comes into the emergency room because of painless, draining foot ulcer. Pressure 175 over 100 and blood sugar is 380. She is unemployed, has never had formal diabetes education. She is scared, particularly concerning who will care for her children if he has to be hospitalized. What I want to do very, very briefly is think about what could have happened to T.J. and what can happen today. Set a framework for the speakers that are to follow me. If I . Page 20 . could have the next slide, please. This slide represents a so-called flux view of diabetes and represents everything that I know about diabetes. Basically it suggests that in the natural history of diabetes not from a biological perspective but in sense from a human perspective, what happens is people presumably start out without diabetes, at least as we understand it today. They precede through a flux point or transition point number one, to where diabetes is present by some criteria. However, just because diabetes is present, either because it is asymptomatic or symptoms are not specific to diabetes such as blurred vision or whatever, initially the diabetes is unrecognized. Has to go through a second flux point or transition point to where for whatever reason diabetes is now recognized. Either blood test has been done, friend or family member, whatever, says you have diabetes. Unfortunately in the United States just because you're told that you have a condition, does not mean that you receive care either individuals in denial or without insurance or without access or whatever. That even though diabetes is now recognized, initially it is uncared for and people have to go through third flux point where they're receiving care. Diabetes, like many chronic conditions, are complex. Inevitably the initial aspects of the care is improper. And only through time and effort . Page 21 . and education a fourth flux point is transversed and ultimately properly cared for diabetes occurs. The natural history of diabetes anywhere. Now, each of the flux points -- next slide. Has a title. A title at which we could conceivably conceptually intervene to reduce the burden of diabetes and help T.J. So, for example, flux point 1 represents primary prevention. If you don't progress from no diabetes to diabetes, you don't have to worry about losing your vision. Point 2 represents potential opportunity to identify unrecognized diabetes early to screening and early detection. Flux point 3 represents opportunity to ensure earlier access in utilization in healthcare services so that there's not a long period of time before one gets into care. And flux point 4 represents the opportunity once you are in care to receive quality care. That quality care would fit into the framework what is called secondary and tertiary prevention. Next slide. What we're going to hear about in the next few minutes are discussions about each of these flux points. Initial representation will be by Susan Feetham who will be talking about access and quality of care, followed by Howard -- issues around early identification of existing diabetes but unrecognized diabetes. And then Allen will talk about primary prevention. Sharing with you the diabetes where we . Page 22 . need to go in each of the areas. The reason we are starting at the bottom in a sense access to quality of care and then moving up to primary prevention is from historical perspective that is the way the science has emerged. At this time we'd like to ask Susan to come forward to talk about programs particularly within HRSA, access, utilization of services, good quality services. Suzanne? >> SUZANNE FEETHAM -- An outstanding program in Bureau from healthcare. For some of you not familiar with health centers, this slide shows you across the United States where health centers are located and all of the territories also that we serve 10.3 million persons in this country. Have now over 3400 sites, majority of patients are under 200% poverty level and 64% are racial and ethnic minorities. You can see we're presidential initiative with expectation we'll expand health centers and serve 16 million and over 16,000 sites by the year 2006. Next, please. We have had an outstanding program for several years called the health disparity collaborative, which is a national effort to improve health outcome for all medically underserved people. You will see as I talk, many of the things you've already heard today are with the programs. Disparities collaboratives that we have had in disease management . Page 23 . include diabetes, cancer, cardiovascular, asthma and depression. Colleagues in the HIV/AIDS we have collaborative on HIV/AIDS. We're starting diabetes and overall prevention as you can see here focuses on healthy weight, tobacco use, blood pressure, immunizations, blood screening and oral health. Next, please. Characteristics of collaboratives are there's six essential elements. Patient and family self management, decision support that goes for our providers, our patients and their families. Clinical information system that I will share data with you in a minute, fundamental to all this is a collaborative start with an expert panel and identify the evidence for best practices. The delivery system and redesign is a major first step in our collaboratives, because again, if we cannot look at our systems of care and provide care in the most efficient manner, it will in fact affect the quality outcome for the patience. Another major characteristics of our collaboratives are they're all community based and engage the community and all of our activities. Slide, please. Some of the successes we can share with you we have many personal stories for patients and their families from homeless person who within 18 months sustained a decrease in hemoglobin a1c, increased control over blood pressure. An older Hispanic woman that came to our center described . Page 24 . herself as depressed, unable to work, unable to engage in activities, again had hypertension, was overweight and two activity and participation collaborative, gained control of diabetes, able to get part-time job, her daughter was also. Again, the downstream effect of the positive outcomes in the collaboratives are extremely exciting. For health centers we hear stories all of the time, system redesign, there are major enthusiasm and attention to innervation within the delivery sites. Centers feel this helps recruit and retrain outstanding professionals. We also have successes in programs that have many partners. And state based partnerships include examples here where the state diabetes control program in Colorado with collaboratives have major accomplishments in improving control of diabetes. National partners are listed here and again, they include federal partners where work is complimentary. Other agencies and also private and corporate partners, as you can see here. Next slide, please. Another outcome is shown. And these are data from one cluster of our collaborative, decrease and heard earlier today of the outcome by just this little percentage decrease in the hemoglobin a1c with the patients and now have these data represent 8300 patients. We have data across over 75,000 patients nationally, phenomenal opportunity to . Page 25 . explore the positive outcomes from these collaboratives. So some of the summary outcome of the collaboratives is that we identify individuals at risk for developing diabetes, we implement a community based life-style modification, which you heard much about today. Support patients and their families to actively participate in the healthcare by self management goals and high percentage of patience identify their own goals and achieve these goals. We also as identify monitor and track clinical outcomes and other measures. Because they're national, we're able to look across to what makes the centers work. And to interpret these outcomes beyond just our own health centers. Next, please. So what are we learning? We have identified that the shared vision of using measures which are based on evidence that we are able to balance the uniformity with invasion. As I mentioned, we have data on over 75,000 patients. We have early and personal development of external partnerships which provide expertise and capacity and help others understand the outstanding outcomes that patience has engaged in centers nationally. To identify models of care and these are powerful and very positive factors in driving change. Another significant outcome is we're able to narrow that gap of the translation of the best science into practice. Next. We are moving as I mentioned on . Page 26 . prevention collaborative. Seen goals talked about today and they're inherent to the first prevention collaborative. Goals with the partners seen and heard from many today and heard more in just a minute, the goal of the Bureau is -- ultimate challenge is we will be the model for primary healthcare in the United States. Next slide. And we feel with partnerships and work we're doing, we're well on the way to accomplishing that. Thank you. >> DR. FRANK VINICOR President Bush and Secretary Thompson are imperative about improving healthcare for all Americans. Next slide. As the Secretary enthusiastically mentioned at lunch, steps to healthy U.S. will help achieve the goal of Secretary Thompson's vision requires combating diabetes. Diabetes is significant health issue facing our nation. As we have heard this morning it afflicts approximately 17 million people in the United States. 17 million which is an incredible number. Costs $132 billion. About 1/3 or about 5.9 million of the people do not even know they even have diabetes. It is the leading cause blindness, kidney failure, limb amputations, cardiovascular problems and stroke. Affects everyone but there are some populations that are hardest hit. Increase of diabetes is on the rise, as we also heard this morning. So it is imperative we identify those with . Page 27 . diabetes and connect them to important preventative services early on in the onset of the disease to prevent the complications that is so devastating. Research has shown we can turn back the clock and dramatically reduce the development of type two diabetes in those that are at highest risk through healthy eating and physical activity. Early detection is also critical for those at high risk for diabetes. Response to the significant number of individuals who do not know that they have diabetes and those who are at risk for the disease, Secretary Thompson is launching a diabetes detection initiative. Slide, please. This important program will bring together numerous public and private partners. The diabetes prevention and control programs located on the health departments in all the states and U.S. territories will serve as the key coordinators for the initiative. Next slide. The state diabetes programs will be joined by the Department of Health and Human Services regional directors and regional health administrators. Next, please. Together these state and regional experts will work with their various partners to distribute a diabetes risk assessment form created by the American Diabetes Association. The flyer takes each person through the risk factors for diabetes and gives a score indicating their degree of risk. Next slide. The results of this assessment . Page 28 . may indicate low risk. Information will be given encouraging the people to keep their risk low. Next slide. But the assessment may also indicate a higher risk. And if one is at higher risk -- next slide -- then they will be encouraged -- next slide. Then they will be encouraged to contact the health professionals in -- in the private practice. Next slide. As well as contact health professionals in the community health clinics. Follow-up counseling from these individuals as well as determining necessary blood tests and other tests to determine their risk for diabetes. Next slide. Now the concern that occurred, that takes care of the population of individuals who have somebody to contact. Next slide. But what if there is no contact individual identified? Then they will be connected to the state diabetes program who will work with them to help them get involved in a system. Next slide. This will allow them to find links to professional individuals who can assist in getting them evaluated for diabetes. Next slide. In addition to that they will be able to provide follow-up evaluation and diagnostic testing as indicated. In addition to what we have described, some states will also conduct diabetes detection days. Next slide. Thank you. Now these days will -- diabetes detection days are part of our whole healthy U.S. initiative. Next slide. Next slide. Thank you. The . Page 29 . diabetes detection days will bring several public and private partners together. They will include pharmacies, private companies and community groups. These individuals from the different organizations will work with our federal agencies to help push forward the whole diabetes initiative. Next slide. During these diabetes detection days activities will go on at numerous sites across the nation in all the states in an effort to find 5.9 million undiagnosed diabetics. Next slide. Next slide. Thank you. Self assessment tests described earlier will be used. Blood pressure will be obtained to check since many individuals with diabetes will be at risk for elevated blood pressure. Some sites may do finger stick tests for blood evaluation and this will be determined according to the state specific regulations. In addition, educational materials will be provided on diabetes and ways to risk -- decrease one's risk will also be identified and provided to the individuals who these diabetes detection days. Those with high risk will be encouraged to go to the health professionals for follow-up evaluation and possible blood testing to determine if they have diabetes. Information about options of enrolling in healthcare services will be provided at that time. Next slide. It is imperative we work together to stem the tide of the serious and rapidly growing health concern. Secretary Thompson is . Page 30 . passionate about identifying the individuals who have diabetes and don't even know who they have it. All people want to be healthy and free from illness. We know that. And we believe prevention is key to improving the health for everyone from families and friends to colleagues and acquaintances. Speaking from my colleagues, Dr. Spiegel, Vinicor, Dr. Veetham, we look forward to working with you on Secretary Thompson diabetes detection initiative. We believe we can do this together and believe start today and take the necessary steps to healthier U.S.. Thank you very much. >>DR. ALLEN SPIEGEL Let me say it is a privilege and pleasure to take part in this important meeting. Terrific speakers that we've heard from both just preceding me and then through the morning and then Fran Kaufman, the Secretary, have made my job easier. Want to reinforce the points they made about type two diabetes and highlight several points been at National Institutes Of Health we support research that creates the science base for improving the health of the American people. Really typified by the issue of primary prevention what we call type two diabetes. Used to be called insulin or non-insulin dependent diabetes or adult diabetes. You can see as I progress why the terms aren't useful anymore. The next slide, . Page 31 . another bit of statistics and data, there have been a lot of statistics flown at you, another way look at the diabetes epidemic. Type two, affects 92% of the roughly 17 million Americans who have this disease. It is growing at enormous rate and projected as you see the red line on the graph to be growing more rapidly than the growth in the general population or the working age population. The next slide you will see then this provides the rational for the prevention trial that we conducted within the last several years. The prevalence of type two increasing in epidemic proportions and interestingly and relevant to the AIDS/HIV situation but in developing countries. Once type two diabetes develops, as we have heard, despite things heard by HRSA, not non-insulin diabetes anymore. Fully 1/3 of the individuals with type two diabetes eventually having to take insulin injections. Type two would result in reduction in the human and economic costs of all these complications that you have heard over and over again. Now the next slide we really describe the diabetes prevention program which is this randomized clinical trial to prevention type two diabetes. And I want to stress, these were in roughly 3500 individuals at high risk. Define what I mean by that. And you can see all the partners both of the N.I.H., C.D.C., American Diabetes Association and private sector that partners in . Page 32 . sponsoring the critical trial. The next slide. Now, the research performed over the years by scientists supported by the N.I.H. has really defined the stages in the history of type two diabetes. And it hasn't just defined what we call the natural history of pathogenesis. It is provided the basis for understanding -- and you heard this referred to by several speakers, reduction in the hemoglobin a1c, control of the blood sugar can reduce the complications, disability and death. Of the new medications that have been developed. When I was in medical school and won't tell you how long ago which was, only had one class of drugs. Now there are multiple classes of drugs beyond just different forms of insulin. But it is clear and those of you have heard Lius speak this morning, N.I.H. is focused on prevention and primary prevention. There's a term impaired glucose colrens or I.G.T. that doesn't really roll off the tongue. It is a technical term. For years the diabetes community avoided the term of prediabetes because seemed as if you were labeling people to be doomed to be developing diabetes. The message from the trial really is that we can and should use the term to identify these people who are at enormously high risk of developing type two diabetes. I'd like to think this of in terms of fleet of pickup trucks. If your body is like one of the pickup trucks and putting . Page 33 . lots of bricks inside the pickup truck, translation, lots of excess pounds, you can imagine that the engine is going to have to work a lot harder. Some of the medications that we use can make that engine more fuel efficient and can help to treat diabetes in that way. But ultimately to really prevent the engine from failing we need to get those bricks back out. And what is that engine? It is the pancreas that makes the engine. When it fails, when no longer makes enough insulin goes from prediabetes into the diabetes, complications, difficult to treat stage. Now in the next slide we look at how we got to this point. Dr. Kaufman already showed you this. Across U.S. people screened, truly high risk individuals. They came from all the groups in his U.S., 45% minorities disproportionately effected by the disease. Randomized into intensive life-style treatment into a drug that makes it more fuel efficient or standard life-style recommendations, placebo. The next slide as -- as the Secretary mentioned during lunch. Data safety and monitoring board, made decision to halt the trial early because the results were so overwhelming positive. And based on that we felt that it was necessary to let the American people know and the Secretary announced this at a press conference in retrospect in tragic events of September 2001, announced the results, what you see first time in one form . Page 34 . here. In every one of the groups in the trial whether they're Caucasian, African American, Indian, all of them represented the life-style intervention in light blue was remarkably effective on average in the entire group 58% reduction in the incidence of diabetes. Really a high risk group. If you look at the placebo group, these individuals were developing diabetes at the rate of ten to 11% a year. The drug was likely effective but less effective than life-style. So in the next slide we need to carry the message from this landmark clinical trial forward, and that's the purpose of the national diabetes education program campaign which the Secretary launched last February, small steps, big rewards. Prevent type two diabetes. The national diabetes education program is a partnership of the C.D.C. Division Of Diabetes Translation, which Dr. Vinicor heads and NIDDK. And the campaign we're emphasizing, even though this was intensive life-style intervention in the clinical trial, what needed to be achieved for these high risk individuals was modest changes in weight, modest degrees of exercise. That's really the flip side of the message of the obesity epidemic. This is a point I want to stress. Just like the fleet of the pickup trucks isn't all the same in terms of the engine failure, this is both challenging opportunity, not everyone who is obese, despite the obesity epidemic is . Page 35 . going to develop type two diabetes. Susceptible, engine, pancreas, can't keep up with the stress. We're targeting those high risk individuals. Next slide gives you the goals of the campaign, create awareness type two diabetes can be delayed or prevented in people with high risk prediabetes state. These are individuals who have a family history of the disease. So they're not just overweight or obese. Have often a family history. They come from the ethnic or minority groups that are disproportionately affected. May if women have history of gestational diabetes. Transient diabetes during pregnancy which is stress and following the delivery the diabetes goes away but they're high risk individuals. This provides the testing for such patients and information to patients and providers what they can do about it. In the next slide you can see an example of tool kit that's provided to the healthcare providers. Game plan tool kit for preventing type two and American Diabetes Association whose booth is outside the door, providing material. Those interested can pick up the materials for patients and providers. Partner with N.D.P. Materialists translated in all appropriate language. Next slide, let me just indicate at N.I.H.,at NIDDK and C.D.C. we're interested in translating these clinical trial results which are very solid, rigorous science into the real world. Need to . Page 36 . be able to be sure the results can be translated into the individuals and communities at risk, particularly under-served minority populations. We have released a request for applications. Encourage applications in real world settings to be able to stimulate research on how best and most cost effectively to translate the results of this trial. Frankly, candidly, even though, even in the trial with the intensive life-style intervention, calculation show this is cost effective. But to be able to afford the prevention, need to make it more cost effective and the goal of this type of research. Next to last slide let me just deal -- I think it is tragically heard doctor Kaufman, the nine-year-old she diagnosed with type two diabetes. That's why it is no longer adult onset diabetes. It is affecting kids. In these kids we now need to know how to treat them better. A treatment trial as she described as being supported by N.I.H., NIDDK, we have treated kids with type one diabetes with insulin for quite some time. That's the form of the disease rarer where autoimmune process destroys the pancreas. Now we need to know how to treat the kids with type two diabetes. And emphasis on prevention. Piloting prevention trial at three sites, Houston, Orange County, California and North Carolina. Education, food services, behavioral component, schools unit of randomization. . Page 37 . Going from the early at risk period in the very puberal period, sixth grade, cohort followed for a few years. Doing oral glucose tolerance test and just did a pilot on that. Why is it so critical? It is critical because we may be at risk of vicious cycle. There's evidence of studies we have supported that women who have diabetes during pregnancy confer an additional environmental risk, not just genetic risk but environmental risk to kids in utero. It could spiral the diabetes epidemic if we don't get a handle on it. On the final slide, message I have for you is based on solid science, prevention is possible. We can identify these individuals with prediabetes and do something about it with your help, with all of you partnering in importance of raising awareness about the condition and recognizing that while diet and exercise is good for everyone, it is these particular individuals, those individuals -- and I say this is both a challenge and an opportunity. Challenge we not stigmatize the individuals. Take advantage of the full power of sequencey the human genome. These individuals can be identified and we can intervene at much earlier stage. Let me just close by saying, of course, we're acutely aware at N.I.H. that obesity epidemic is what's driving epidemic of type two diabetes. As the Director of National Institute of Diabetes and Kidney Disease I have responsibility for . Page 38 . liver disease. Second most liver disease after Hepatitis C. Cancer, heart disease, variety of other diseases, all comorbidity of obesity. Again here the challenge and opportunity, tremendous basic science advances that I don't have time to tell you about indicate that even in this obesegenic environment preceding speaker referred to, we're not all equally susceptible. Amazingly despite the marks and everything else, maintaining remarkably level of body weight. This is new to biologic differences beginning to understand and tease out. We want to be able to harness those things to really be able to prevent obesity in very cost effective way. Science that's being supported in coordinative way at N.I.H. will eventually do that and also impinge on this diabetes epidemic. Thanks for your attention. >>DR. FRANK VINICOR Let me return to this slide to summarize some of the issues. Slide and one more to go. We have heard comments addressing both the science as well as emerging programs dealing with each of these four flux points. Of all, it is important to point out in each of these points this is not a responsibility that can be accomplished by only dealing with either public health or clinical medicine. Of these points requires some positive coordinating interaction between the public health . Page 39 . community and the public health concepts and clinical community and clinical philosophy. That's the first point I want to make. Point I want to make is regarding a flux points three and four, access and quality of care. There's clear evidence that things are getting better for people who have diabetes. Almost all the studies show that not only preventative behaviors by health professionals or by people with diabetes, but also important outcomes are beginning to diminish. Glass is no longer half full or half empty, it is probably 3/4 full. Things are better if you have diabetes than it was ten or 20 years ago. However, that has occurred because of a lot of effort and creativity, but the concern within the diabetes community is this progression and improvement in quality of care may soon level off in regress as this epidemic of type two diabetes begins to emerge and begins to in essence swamp the clinical care systems. Whereas now we're spending 17.2 minutes with face time with someone with diabetes, with more and more and more people coming in, particularly if the healthcare system doesn't change, we're going to see less and less time that we have available to spend with people with diabetes and quality of care may go down. Above and beyond ethics of implementing good science that Dr. Spiegel was talking about, we have the requirement I think to ensure we . Page 40 . continue to improve quality of care and not allow the epidemic to overwhelm am us. Of the flux points has some pluses and some minuses. Just to plant seeds in your mind, if I could have the final slide, I just opposed some general challenges for you to think about, no doubt into the evening and throughout the next day and on infinitum but we're in fact operating in world of limits. So choices must be made. And the question is how do we choose among these four diabetes intervention options and who should make these choices I don't think any of us here necessarily have the answer and we don't have time. Naturally to discuss this, but I think that will be the next raised challenge for the clinical and public health diabetes community is finding ways to make appropriate choices among each of the four interventions. One of which can make a difference in the lives of people at risk for or with diabetes. Thank you. >>DR. HOWARD ZUCKER Keeping on time for Elizabeth, I just want to thank the whole panel once again. Important to note that the four of us who spoke are just part of enormous team that the Secretary put together in looking for diabetes and finding the 5.9 million Americans out there. The Secretary would like those 5.9 million found by last month because it is in keeping with getting the job done. Hoping to roll . Page 41 . this out in the fall. If there's anything that any of the participants here would like to provide and contribute, find us at the breaks and give us information that you think would be helpful to the initiative. My privilege to introduce the next speaker, Ann Marie Lynch. Department at Health And Human Services and Deputy Assistant Secretary for Help Policy and Office of Assistant Secretary for Planning and Evaluation at H.H.S. She is a wealth of knowledge. I spoken to Ann Marie many times about issues of spectrum on healthcare. Has impressive record having served as Vice President for Policy at --, has worked on Capitol Hill in many different committees, as well as economist at C.M.S. several years ago. Ann Marie? >> ANN MARIE LYNCH Thank you, Howard. I am pleased to be here today. Have already heard that to improve the nation's health it will take partnerships with the states, with the communities, with schools and with face based organizations. Among those partners must also be the private sector. The private sector including businesses and foundations has the capacity to reach millions of workers and families in this country. Has the resources to support programs and health events and is primary provider of healthcare. If we are going to change the . Page 42 . health delivery system, the private sector must be a part of those efforts. Exchange prevention for treatments, encourage preventative screenings and to provide prevention education. Only through a collective effort of both the public sector with the private sector will our ultimate goal of healthier U.S. be achieved. At this point I'd like to introduce members doing great work to make contributions to prevention. Mitzi Perdue and Allen Monique join us here. Misty Purdue is artist, author, lecturer, broadcaster and community organizer. She holds degrees from Harvard University, George Washington University and the organization she founded, Healthy You, encouraging healthy life-styles in Maryland's lower shore. Healthy You, is a coalition of 168 groups including hospitals, churches, health departments, nonprofits and others. Participants include 4,500 individuals who have signed on for a program that involves education, incentives, team work and competition. Mitzi Perdue. (Applause) >>MITZI PERDUE Thank you so much, Ann Marie. Appreciate the introduction. I hope I can move away from the Mike and you can still hear me. Appreciate the chance to come here because I want to tell but an experiment. I'm not sure it is scientific experiment but it is experiment may . Page 43 . work or may not work. Experiment as to see if you could get a whole community and our case 156,000 people who live in the three lower shore counties of the eastern shore of Maryland, see if you get them all together and as a community try to do something about the risk factors that lead us to have such unfortunate rates of I guess the word is prevalence as long as I'm talk with doctors of heart disease, cancer and diabetes. Experiment as Ann Marie mentioned, see if education, rewards and change in the environment, plus team work, if you put all those together and use every aspect of the community, including churches, places of work -- and I should say house of worship because we have mosques and we have temples, it also -- it involves the schools, it involves the nonprofits. To explain how this thing works, I want to tell about it kind of sequentially. It began pretty much in May of a year ago. I'm an American diabetes volunteer. If Fran is around, I just mentioned diabetes again. She was keeping count. I'm an American Diabetes volunteer but hang out with people from other nonprofits, including people from American Cancer Society. And the local head of American Cancer Society was telling me the research they had. View of wonderful information you're giving me, how come you're not out in the community talking in the schools every day, on . Page 44 . television every day and radio every day? How come we all don't know this? She answered what I take to be really important obstacle. Obstacle that she faced in which all the nonprofit health organizations face is that if you're head of say general manager of television station, if you're running the school, and you love her message, which you probably would, but you're going to have to give a vast amount of time to other people, if you give her vast amount of time, I asked her in view of the obstacle, what would happen if American diabetes was -- speaking locally in all cases. What if American Diabetes Association and American Heart Association and some of the other nonprofits got together and gave the same message because as it has become clear as we listen to the speakers this morning, the same risk factors cause the same diseases. It is smoking, lack of exercise, it is poor diet. Well, she liked the idea. We went around to visit other nonprofit organizations. Something like a couple of months we had 48 nonprofit health organizations signed on, including with local medical societies, including all the hospitals, all the nonprofits we could get our hands on. As soon as what I thought to be fairly large number for a local area, as soon as we had 48 coalition members and incidentally being coalition member meant if you belonged to nonprofit health or whatever organization we're talking . Page 45 . about, if you belonged to the organization, we want you to serve on one of our committees and we want to you support our goals. Well, it was a really easy sell because everybody did. 48 nonprofit health organizations and other organizations signed on, we went to the local news papers and radio and television and asked, would you help us in campaign that would begin in the year 2003, what could you give us to support it? Well, guess what? All the media loved the idea because they told us we want to help. But we face the reverse of that obstacle I just described. We want to get the message out, but we can't focus on one organization. But we could absolutely focus umbrella organization. In the space of about a month we got committed half million dollars worth of radio, television, billboard, newspaper space. They have been just so generous. They have been delivering since too. Local newspaper gives us full page and front page of style section every Monday. Okay. So now we're in position to have a really good educational effort. But from our point of view education is really wonderful. But it is kind of baby steps. It is not the real steps that you read about in steps to a healthy U.S.. I've read cases where you take 100 people and you tell them all you risk fatal disease unless you lose weight, and a year later, 95% of them haven't lost weight. Most of them have . Page 46 . gained weight. Education by itself, we felt wasn't going to do the trick. What could we add to the mix? We came up with incentives and incentive we came up with, we wanted something big that would get attention. The reward that we came up with is drawing for brand-new car. That's part of it. If you join Healthy You, which means you get weighed and measured, B.M.I. gets taken and do year later just for participating, you're eligible for drawing for brand-new car. But if you improve and done with a buddy because we wanted to engineer team work, if you do this with a buddy, you not only get -- you not only get the car, the buddy gets equivalent car and get all the gas and insurance paid for year for both of you. That's to encourage people to join as buddies. We also have -- felt year is too long to ask people to keep health in mind. So we instituted monthly drawings. 12 times a year we have drawings of between 1,000 and $1,200 worth of gift certificates and savings bonds to reward people with healthy life-styles. Walking club, joined a gym. If they attend that -- they have a Healthy You car. Check in, give number the car, gym gives us the number and have the drawing from it. Most recent drawing we have, few weeks ago, 62% of the people -- right now close to 4800 people who have signed on, 62% of those people cared enough about the drawings to have the . Page 47 . numbers registered. We felt that which was -- that which was but not enough to do the trick. What I'm about to describe is really the heart and soul of Healthy You. To show it I have to give illustration. Ladies and gentlemen, behold the Hughie Award. This is award designed by local artists. And the organization -- how are we doing on time? Tell me how many minutes I got left (off mic). Yay. Five minutes. Hewie goes to organizations that do the most to encourage environmental change that support a healthy life-style. Categories houses of worship, businesses, nonprofits and so on. You can win the Hewie if you do things truly approach at for your organization that are kind of innovative and really work. I'll give you a couple examples. There's an organization, a call center where the average weight of the first groups that we were measuring, those groups have -- average of 238 pounds. 148 woman, sedentary, making calls for eight to ten hours a day and they eat all day long. Well, they are aware of the health issues that being sedentary and overweight cost them. They in matching their own culture they have -- they voted they would ban birthday cakes. They felt it was no favor to somebody who is battling a weight problem to have a birthday cake. Instead they give them a great big fruit basket. They have about 20 other things to support or compete for the . Page 48 . Hewie. Blind industry, if you're blind, it is not easy to go out jogging. Do you get your pulse rate up? What they voted to do, instead of coffee and candy breaks, blind industries, I think there are 80 of them, they sit in their seats and move legs up and down and got resistant bands and kept heart rate up 15 minutes three times a day. I talked with group of American Indians. American Indians -- they haven't voted on this yet but can't swear they're going to do it. Going back to native foods. Skipping McDonald's. Every organization comes up with something that's so appropriate for them and their people buy into. Every organization that I've talked with, there are hundreds, coming up with own ways of, you know, kind of translating into what their people will accept. It is something that centralized could never have been done. It is kind of neat this incentive and incentive and local community players is going to put on a academy award style event. Let me jump into what it took to do it. Our budget is $150,000 a year. We spend -- we spend close to 1 million and a half and it is all donated. Wanted people to donate, first of all because we didn't have the money. But second, if you feel you have given something and absolutely committed to it. What I have described we don't know the answer to it yet but we will know in April a year from now because we will have 5,000 . Page 49 . people, that's how many we expect, 5,000 people, and we can tell whether their weight has changed and whether we have a health survey they have answered. We'll see if combination of community wide effort with incentives and rewards and team work, if it does get us closer to the healthier U.S. Thank you very much. (Applause) >>ANN MARIE LYNCH Thank you so much, Mrs. Purdue for sharing with us today and dedicating energy to the important work. Private partner is Dr. Allen Muney. Chief Medical Officer and Executive Vice President of Officer Health Plans. Joined Oxford Health in 1998 and is responsible for medical management, medical program and policies, quality management and physician relationships. 1995 to 1998, Dr. Muney, he was Vice President of Medical Affairs at Health Systems, division in New York. He was with Milkin Medical Center corporate responsibility for quality management, utilization management, medical policy and merger acquisition activities. Muney was Regional Medical Director for the Los Angeles region. Welcome, Dr. Muney. >> DR. ALLEN MUNEY Thank you. I'm going to talk to you about an experiment today and what we're doing at Oxford to link our sickest members with the right physicians. Reasons to do so are . Page 50 . very compelling. How we do it and the results of this project are really I think key to creating the links and gaps and accountabilities that now exist. First let's start with why we do it. You saw some data earlier today from New York state that showed rather impressive improvements in hemoglobin a1c testing and health plan scores through N.E.C.A.. So great news 79% of testing rate, which was about the 90th percentile, only half of those only resulted in those patients that were in diabetic control. We have a long way to go. When we look at our own data, the reasons for us to embank on this linkage of six members to the right doctors was very compelling. Of the 1.5 million members we have, only 3% of the members drive over half the cost. When you drill down into those buckets, you find that not surprisingly there are lots of diabetics, people with heart disease and people with cancer. When you go down into the buckets of congestive heart failure and diabetes, which is what this pilot program is addressing, you find at least what I found to be some rather startling results. Prevention has always been near and dear to heart literally, as my dad died when he was 49. Brothers type one diabetes for 25 years. So not only primary prevention but secondary prevention is a pretty passionate topic. When we looked at our data, we found . Page 51 . in congestive heart failure the 1200 of our sickest patience which are the patients we identified to have electronic scales put in their homes, only 400 out of the 1200 patients who were the sickest congestive heart patients had actually seen cardiologist in over a year. Diabetic patients 3400 of the six diabetics who we defined as having hemoglobin a1c, 2800 out of the 3400 did not see endocrinologist in over a year. So you have to ask yourself really what's going on here in the healthcare system. There's ample literature to show that certain patients with these diseases do better in specialty care. And the lessons we're learning from this, as we're five months into this are many. What are some of the reasons? Certainly as the Institute Of Medicine report pointed out in 1991, the care processes in healthcare system are very fragmented. Primary care physician and noncompliant both following guidelines and following physicians advice. There's lack of family support, there's lack of office time in the physician's office to support. And all of this comes up as an argument quite frankly and we're talking about in the private sector now of who is account believe for the clinical quality and healthcare? Is it primary care physician, is it specialists? Unfortunately I believe until that is resolved a definition of accountability for outcomes in healthcare, then many patients are going . Page 52 . to continue to have random walk through healthcare which ends up very unproductive in terms of quality and unfulfilling in terms of satisfaction. Are we doing in our pilots? I will use the diabetic pilot as the example. And we'll talk about how we identify the better physicians. Our physician identification, member identification, and a very key component to this is what is our referral strategy of getting that member to the right doctor and as you can imagine among physicians, it is caused quite a lot of discussion. When we look at the physicians, we decided to use the N.C.Q.A. certification program that's partnered with the A.D.A.. We also decided at least the first two limited to endocrinologist and build a network that way. We also used some of the data in terms of the number of members and outcomes as well as index of clinical efficiency meaning who delivered the outcomes at the lowest cost as the basis for a network. Then prioritized who we sent the members to by using those criteria. And embanked on them identifying the members. And the way we identified the members was the list that I mentioned, which was the 1200 thickest congestive heart failure patients and 3400 of the sickest diabetics. We then concentrated on the referral strategy. Again, remember these are patients that have not seen a specialist in more than a year despite having laboratory . Page 53 . evidence in diabetes, for example, of at least having hemoglobin a1c checked. So the referral strategy we ran focus groups among primary care physicians, specialists and members to come up with an acceptable strategy that we believe will get us to the goal. We did not want to interfere with the relationship between the patient and the primary care physician, and in fact, as part of the referral strategy in order to get them to the specialist, we engage the primary care physician and advocated on their behalf in terms of how we communicated to the member. Along the lines of your primary care physician is concerned and really would like you to see a specialist. This was acceptable to all the parties that we ran this by in terms of the focus groups. We put out initial failings and phone calls to the primary care physicians. I can tell you by being involved with physicians for almost 20 years and several management positions with them, there isn't a physician who when presented with credible data wants to be out in left field compared to their peers. It is just -- competitiveness the way it is. So that works to our advantage in terms of engaging the primary care physician in this initiative. The next strategy was what are we going to measure? Diabetes it was a little bit easier in terms of hemoglobin a1c and lipid profiles, E.R. visits and hospitalizations. And how were we going to get people . Page 54 . to really buy into this. This turned out to be our pay for quality strategy when we built the endocrinology network, we placed financial incentive both in terms of office compensation for taking care of these sicker members that get referred to them to address the time involved. Also paid for the certification for the N.C.Q.A. program. So as I said, we're about five months into this right now. And things at least we have -- appear to be going well. We have 500 of our members between both the diabetes and congestive heart failure program. The C.H.F. pilot is a little bit more difficult in terms of trying to decide what the better physician management is just due to the fact that there's not great agreement among cardiologists. We have met with many of them, and finally settled on a combination of prescribing patterns for the drugs to treat congestive heart failure. The patient's selection was as I indicated. Referral strategy was some what the same and the monitoring and tracking of the results are going to be based on the E.R. visits and hospitalizations. Now again, to show the true value of disease management, trying to have a health plan actually insert itself into a referral patterns between doctors is not an easy thing. You know, this is not your father's disease management program here. But we believe that the basic disease management programs that are in existence today which . Page 55 . are essentially case manager contacts on behalf of the physician and to the member with behavioral changes was not sufficient in the time frames that we thought were important for secondary prevention to get to the goals that we have all heard about today, which is lowering hemoglobin a1c, for example. For that reason cost of gap of costability, be in a position to facilitate those linkages between primary care physician, information flow, case manager support of arranging those evaluations and appointments and the specialists who we believe really should be taking care of the patients. As I said, this is a work in progress. But at the end of the day, I believe that if we do it, this will be an excellent pilot to look at other places in which lots of expenditure in the same area, be it Medicare, Medicaid and lots of data importantly to look at how to create those accountabilities in terms of who is actually practicing appropriately according to the clinical guidelines. So in the end, we're hopeful that it is going to make a difference and some point hopefully we can report back on that. Thank you. (Applause) >>ANN MARIE LYNCH Thank you very much for sharing with us some of the exciting preventative work that you're doing in your plan, with the same focus of improving healthcare, which is . Page 56 . terrific. Mitzi Perdue has one more item that she would like to share with us. So I'd like to invite her back. >>MITZI PERDUE I wonder if I'm still mic'd up. As Long as we have three minutes more -- five minutes. I wanted to get into the nuts and bolts how I went around recruiting 1,000 volunteers, which is what it takes to make Healthy You run. The way it got 1,000 volunteers is the way Mau took over China. Don't know how Mau took over China? No. Starting with one person, that one person recruited ten. Asked those ten to recruit ten more. We very soon got up to 1,000 people that I wanted. Because we needed 1,000 people to do the weighing and measuring of 5,000 people. Actually and in fact it was 100 volunteers who agreed to do the weighing and measuring. If you have a data bank of 1,000 people. Again, this is kind of nuts and bolts of how this community organization works, with 1,000 volunteers, whatever you want you're likely to find somebody who is able to do it. So accounting donated, office space donated, printing donated, got car donated, billboards donated. Extremely helpful to have large data base of people. Got all the information technology, the web page, some kind of thing donated. One of the things that we work extremely hard on was we wanted to be as . Page 57 . inclusive as it is conceivably possible to be. And to do that we particularly recruited people who might not normally be involved in the community activity. I'll give you an example. In our area population of 156,000, there are 1,000 Koreans. I'm told they're almost never included in any community organization. Partly language barrier -- just not easy to reach them. We felt we could reach them through the churches and it worked. We have hundreds of Koreans that are part of it. Same with American Indians -- actually we started out the whole program with African Americans, going to African American churches. I felt if they didn't like the program it didn't have a chance. Fortunately they did like it. Another thing that might interest people who if you're thinking of starting a program like this, we're initially afraid that the people who wanted -- excuse me. People who needed the program most might be the least likely to sign up. To my great pleasure and surprise every time that we say go to -- lets say business, couple hundred people, first people to sign up because they want to be included are the people who need it most. One other comment and I know that we're starting -- I think I have one minute. Let me tell you what I kind of hope for for the future. Right now I'm very, very optimistic about it working because I cannot walk down the street without . Page 58 . several people coming up to me and telling me that they have joined a walking club, lost five or 10 pounds or other things that they're doing. I have families tell me that after a meal instead of watching T.V. they turn it off and go for half hour walk. You know, I won't know for sure until the end of the year, but I'm very, very encouraged by how much of community thing it has become. State's attorney told me if not one person changes any part of the life-style, just the effort of the community in something that's so broad based and so inclusive and welcomes and embraces and celebrates everybody, regardless of their health status, regardless of whether they're in wheelchair or blind or whatever, we want them, we embrace them, we include them, and I think it is a good community thing, even beyond whatever it does for the physical health of the community. I don't want to stand in the way of you and a coffee break. (Applause) >>ANN MARIE LYNCH Thank you so much. For your second healthy break, may I suggest you take some -- put some steps on your pedometer or take advantage of the healthy snacks but be in your seats by 3:45 for the current session. Thank you very much. Reminder that the opening session begins at 8:00 a.m. tomorrow morning. See you there. . . Page 59 . . .