Concept Paper

In support of the

Vista Total Health Network

Phillip Longman Senior Research Fellow New America Foundation 1899 L St., N.W., Ste 400 Washington, DC 20036 (202) 596-3415 Longman@newamerica.net

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Table of Contents
Executive Summary.............................................................................................................. 3 Vision Statement................................................................................................................... 4 Proof of Concept ................................................................................................................... 4 Replicating Veterans Healthcare for Civilians....................................................................... 7 The Opportunity Presented by a ........................................................................................... 9 Post-Reform Healthcare Market ....................................................................................... 9 Implementation of the Network ......................................................................................... 10 Market Differentiation........................................................................................................ 12 Business Model Advantages ............................................................................................... 13 Refinements to the Delivery Model .................................................................................... 15 Key Personnel: Early Stage Development ........................................................................... 16 About the New America Foundation .................................................................................. 18 About the New America Healthcare Policy Program.......................................................... 18

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Executive Summary
A proposal to link existing public heath clinics, community hospitals and other non-profit healthcare and social service organizations into a digitally integrated, virtual network patterned on veterans health system. By adopting the VAs health IT platform, protocols of care and quality standards, this network of affiliated accountable care organizations would replicate the best features of the VAs delivery system model while also avoiding some of it shortcomings.

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Vista Total Health Network

Vision Statement
This document provides a vision statement and preliminary business plan for the development of an innovative non-profit, nationally integrated, healthcare network. The delivery system model this network would deploy is currently not available in the private sector. It has, however, proven to combine low cost and high quality care with exceptionally high rates of patient satisfaction. Provisionally referred to here as the Vista Total Health Network (VTHN), the organization is poised to become a major mechanism by which healthcare delivery system reform is achieved in the United States and the means by which a plurality of Americans receive healthcare within the next decade. The public policy environment surrounding American healthcare has not allowed for the emergence of such an entity until very recently. Yet passage of the recent healthcare reform legislation, (particularly the mandates and subsidies created by the Affordable Care Act and the Health Information Technology for Economic and Clinical Health Act), combined with ongoing trends toward commoditization in the healthcare marketplace, have created an unprecedented business opportunity to implement transformative change in how healthcare is delivered in the United States. By linking existing public clinics, hospitals, medical schools, and social service organizations into a digitally integrated, virtual network, and by adopting protocols of care of proven effectiveness, VTHN will offer a new, self-sustaining model of health care with broad market appeal.

Proof of Concept
The delivery systems proof of concept derives primarily from the quality revolution in clinical practice and outcomes research engineered by the veterans health system since the mid-1990s. Though often confused with

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the military health system administered by the Department of Defense for active-duty personnel (which several years ago attracted much press criticism related to conditions at Walter Reed Army Medical Center), the healthcare system operated by the Department of Veterans Affairs (VA) has emerged as a quality pioneer in American medicine. A vast literature of peer-reviewed studies, published in such prestigious venues as the New England Journal of Medicine and the Annals of Internal Medicine, plus the glowing testimonials of the American Legion and other veterans service organizations, documents the extraordinary success of the VA in improving outcomes and patient satisfaction while containing costs. Because of the quality of care it provides, the VA has seen enormous growth in market share in recent years as veterans vote with their feet and enroll in the system despite tightening eligibility rules and considerable copays. Further indicating the consumer demand for this product, at the top of the Americans Legions legislative agenda are proposals that would allow veterans to use their Medicare entitlement at VA hospitals and clinics, and that would allow their family members to use Medicare or private insurance to access the system as well. At a time of galloping healthcare inflation elsewhere, the VA has also been able to keep its costs per patient essentially flat over the last decade. The VA has turned in this unprecedented performance even as it has had to treat the wounded of two ongoing wars (many of whom would have died of their injuries in previous conflicts due to lack of body armor and less effective emergency medicine) and a general population of veterans whose members are, as a group, older, poorer, and more prone to chronic illness than the U.S. population as a whole. Though precise cost comparisons are not available due to differences in the populations served, there is reason to believe that the VA model has a cost per patient that is about 20-30 percent lower than of the rest of the healthcare system, even as it produces both higher quality care and patient satisfaction.1
The foundation document for the VA quality revolution is Kenneth W. Kizer, Vision for Change A Plan to Restructure the Veterans Health Administration. (Department of Veterans Affairs, Office of the Undersecretary for Health, March 17, 1995). http://www4.va.gov/HEALTHPOLICYPLANNING/VISION/2CHAP1.pdf. A popularly written description of the VA quality revolution and its implications for healthcare delivery system reform is Phillip Longmans Best Care Anywhere: Why VA Healthcare is Better Than Yours (Polipoint Press, second edition, April 2010). In their book, The Innovators Prescription: A Disruptive Solution for Healthcare, Clayton M. Christensen,
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While the veterans health system has many features that make it unique, it is helpful to think of it as essentially a large, integrated, staffmodel Health Maintenance Organization (HMO). Its doctors are salaried and it operates within a fixed, or capitated budget as opposed to receiving fees for service. Were it not for its eligibility restrictions and lack of compensation from Medicare, the VA could well generate enough revenue to cover its own costs and become a free-standing, self-funding entity, according to such experts as former Veterans Health Administration under-secretary Kenneth W. Kizer, and work done by the Commission on the Future for Americas Veterans. While each of these aspects is incredibly impressive on its own, the VA has also managed to build a system which has true interdisciplinary and community-based at its center. Under the VAs reform, national quality standards are enforced, but decision-making on implementation is largely at the regional and local level. Social services coexist with robust primary care teams, all with the goal of creating truly patient-centered care. The Vista Network will take this model of excellence to the next level by applying its principles to the general health care delivery system of the United States.

Jerome H. Grossman, and Jason Hwang cite the VA health system as among a mere handful of healthcare providers that have the scope to create within themselves a new disruptive value network (McGraw-Hill Books, 2009, p. 203). Key peer reviewed studies include: Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the veterans affairs healthcare system on the quality of care, New England Journal of Medicine 2003; 348:22182227. http://content.nejm.org/ (Type title into Web sites search box.); Kerr E, Gerzoff R, Krein S, Selby J, Piette J, et al. A comparison of diabetes care quality in the veterans healthcare system and commercial managed care. Annals of Internal Medicine 2004; 141(4):272281. http://www.annals.org/content/141/4/272.full; Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 2004; 141(12): pp. 938945; Selim AJ, Kazis LE, Rogers W, Qian S, Rothendler JA, Lee A, Ren XS, Haffer SC, Mardon R, Miller D, Spiro A 3rd, Selim BJ, Fincke BG. Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans Health Administration. Medical Care 2006; 44(4):359 365.

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Replicating Veterans Healthcare for Civilians

The creation of a civilian VAthat is, a large government program that directly provides healthcare to Americans of all backgrounds as the VA does for qualified veteransis a political non-starter in the U.S. for the foreseeable future. It would, at a minimum, require an act of Congress and new appropriations at a time of healthcare reform fatigue and mounting fiscal pressure. Critics would also charge--and they in this instance would be right--that the proposal would amount to socialized medicine. Yet the opportunity now exists for a non-profit, non-government organization to emerge that would perform much the same function as a civilian VA. The essential idea is to link existing public heath clinics, community hospitals and other non-profit healthcare and social service organizations into a digitally integrated, virtual network. By adopting the VAs health IT platform, protocols of care and quality standards, this entity would replicate the best features of the VAs delivery system model while also avoiding some of it shortcomings. The Vista Total Health Network would build upon these three essential ingredients of the VAs quality transformation: The shrewd, widespread deployment of open-source health information technology. The VAs world renowned VistA software system (written by doctors for doctors) is a key to its success in both day-to-day clinical practice and in the development of evidence-based protocols of care. Because of its open-source development model, VistA long ago won widespread acceptance among the systems doctors and nurses, who were intimately involved in its creation and evolution. VistA is not a code; its a process, is how one of its key developers puts it. This process has fostered a medical culture that by now has put the VA at least twenty years ahead of the

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rest of the U.S. healthcare system in exploiting the full potential of digitalized medicine.2 The VAs scale, integration, and long-term relationship with its patients. The VA operates the largest integrated healthcare system in the United States, which is a key to its quality and cost-effectiveness. Unlike private sector HMOs, much less feefor-service providers, the VA sees very little churn in its patient population. Its relationship with patients typically begins after they leave the military, and, regardless of where they may subsequently move throughout the United States and its major territories, often extends to the provision of long-term nursing home care decades later. Because of these features, the VA, almost uniquely among U.S. healthcare providers, has both the institutional means and the motives to make long-term investments in patient wellness. These include, most notably, investments in prevention, primary care, effective management of chronic conditions, and attention to non-medical determinates of health, such as substance abuse, mental health counseling, racial disparities, and alternatives to institutional long-term care. The VAs culture of public service and commitment to science. Through a process of self-selection, the VAs workforce of salaried managers, doctors, and other healthcare professionals tend toward an ethos of service and commitment to medical research above concern for individual profit maximization. One of the VAs prime recruitment tools is the sense of fulfillment most of its doctors derive from being able to treat patients without regard to concerns such as malpractice insurance, dealings with third-party payers, or marketing and administrating a private practice. Another is the VAs affiliation with medical schools, where many of its doctors hold faculty appointments, allowing them to also engage in teaching and research.
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See, for example, Colene M. Byrne, Lauren M. Mercincavage, Eric C. Pan, Adam G. Vincent, Douglas S. Johnston, and Blackford Middleton, The Value From Investments In Health Information Technology At The U.S. Department Of Veterans Affairs, Health Affairs, April 2010; 29(4): 629-638.

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The Opportunity Presented by a Post-Reform Healthcare Market

To date, being the low-cost provider in healthcare has not generally brought greater market share. Primarily, this has been because most people covered by healthcare plans are insulated from its price, while many others have had the option of simply not purchasing health insurance. The recently passed individual mandate, however, will change the dynamics of the health insurance market dramatically once it goes into effect in 2014. Millions of Americans (including young invincibles who currently can afford healthcare insurance but choose not to buy it) will no longer have that option. Nor, under reform legislation, will they have the option of satisfying the mandate by purchasing very high deductible coverage with many exclusions. Thus, the low cost of the product offered by Vista Total Health Network, which would be listed on the state health insurance exchanges called for by the Accountability Act, will be a very powerful sales point. Its advantage in quality may not, at first, be as important in driving consumers to the Vista Total Health Network. Many consumers still view unrestricted access to specialists as the only key metric of a healthcare plans quality. Yet as more and more Americans become sensitized through their own experience as well as through media reports to the hazards of medical errors, over-treatment, dangerous drugs, and poorly coordinated care, the appeal of a model of care that has a demonstrated ability to provide quality and patient safety will loom ever larger. To be sure, there will always be niche competition from healthcare plans emphasizing unfettered access to any specialist who has hung out a shingle. Yet the common wisdom in the industry is that both healthcare itself, and healthcare insurance, are becoming low-margin, commodity businesses, due to both ongoing marketplace trends and changes in the policy environment. Specifically citing the cost-effectiveness of the VA model of care as a prime example of the potential for disruptive change in
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healthcare, Harvard Business School professor Clayton Christensen predicts that healthcare will soon undergo the same transformation as steel and computers and many other industries in which low-cost producers have vanquished more sophisticated high-end producers.3 In a healthcare world of shrinking or non-existent margins, the Vista Network should not have trouble recruiting the specialists and affiliated institutions it needs from among those seeking safe harbor.

Implementation of the Network

The Network would be implemented starting in selected fractured healthcare markets, where the healthcare delivery system is particularly broken and yet where local political conditions and medical leadership are also favorable to reform. Across the country, healthcare providers of all stripes, including but not limited to safety net hospitals, are facing challenging conditions, including looming mandates to install health IT, the prospect of cuts in Medicare reimbursement rates, an expanding population of Medicaid patients on which it is difficult to break even, cuts in state and local funding, and many other well-known factors. The crisis is more acute in some parts of the country than others, and there is also great variation in the strength of local reform efforts. Early indicators point toward locations in one or more of the following states where conditions are particularly ripe for the launch of the network: Massachusetts, New Jersey, Missouri, Texas, and especially specific regions of California such as that surrounding Bakersfield. As a bellwether state facing a particularly acute fiscal and healthcare crisis, California is a very likely candidate for an initial launch of the network. Building of the network would begin by approaching existing public heath clinics, community hospitals and other non-profit healthcare providers and offering a deal with these essential outlines:
Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang, The Innovators Prescription: A Disruptive Solution for Healthcare, (McGraw-Hill Books, 2009). See also Christensens May 13, 2008 lecture at the Massachusetts Institute of Technology, available online at http://mitworld.mit.edu/video/594.
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Access to newly available federal subsidies. The Network would agree to furnish these organizations with the expertise, staff work, and contacts needed to become qualified for newly available federal subsidies. These would include some $12 billion in funds available to entities that qualify (or can be made to qualify) as accountable care organizations under the terms of the Affordable Care Act. Subsidies, totaling around $17 billion, would also be made available to providers who can demonstrate the meaningful use of Health IT under the emerging regulations of the Health Information Technology for Economic and Clinical Health Act (HITECH). Technical assistance in installing and implementing VistA. The Vista Network would further assist non-profit in implementing Health IT by arranging for the installation of the open-source software originally developed by and currently used by the VA health system. A substantial consulting industry, supported by a vibrant open-source community active around the world, has experience in both installing VistA software in such facilities, and in implementing its use. A recent notable example is the highly successful installation by Medsphere at Midlands Memorial Hospital in Midland, Texas. Perot Systems is currently engaged in a similar project involving the entire healthcare system of the country of Jordan. Importantly, VTHN would also offer upfront grants and bridge loans to its affiliates to finance the installation of VistA during the period before which they could demonstrate its meaningful use and thereby qualify for HITECH grants. Financial assistance in building capital reserves. Many of the institutions the Vista network would be targeting face shortterm cash flow difficulties and longer-term capital inadequacies. In some instances, these shortfalls are sufficient to make it difficult for them to compete for managed care contracts, including with state and local governments. The VistA Network would provide such institutions with bridge loans and in some cases capital infusions.

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In exchange for these and other services, including group purchasing arrangements and help with marketing and lobbying, the Network would require participating non-profits to become formal, branded affiliates adhering to common protocols of care and quality standards. Initially, these protocols would be primarily based on current practice patterns at the VA, including its formulary, patient safety measures, and the full digitalization of patient records and outcome measures. Over time, these protocols would be adjusted to take into account emerging best practices (wherever they might come from) and new findings in comparative effectiveness research. As at the VA, the process for determining practice patterns would strategically involve practicing doctors and other front-line personnel in the field, and would take into account the special needs of local populations. Affiliates would also be held accountable for their performance, which, through the use of a fully integrated health IT system like VistA, becomes comparatively easy to measure and monitor. In this way, a virtual, civilian VA would be rolled out, but based on a networked, non-profit model. Its existence would not involve the creation of any new entitlement, nor require any act of Congress.

Market Differentiation
The closest existing approximates to the Vista Total Health Network in todays marketplace are large, non-profit, staff-model HMOs such as Kaiser Permanente. However, there are critical points of distinction. To begin with, Kaiser, like nearly all managed care providers in the United States, has struggled for years to deploy proprietary Health IT. These efforts have not succeeded to anywhere near their full potential for several reasons, and in many instances have simply failed. The reasons include the widespread rejection of proprietary Health IT products by practicing doctors, who often complain that these software programs are cumbersome and even dangerous to use. Also involved are the inherent limits to transparency, integration, and innovation that occur when trade secrets dominate the development of Health IT and medical

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data becomes locked in black boxes controlled by private venders. In contrast, VTHN would deploy a continually evolving open-source VistA platform. This platform combines low cost (the code itself is free) with an ability to be easily modified to meet the changing, or special needs of different healthcare providers while also allowing for seamless interface among them.4 Another point of distinction is that VTHN would not, as a rule, contract with for-profit, physician-owned, medical partnerships, as does Kaiser and most other managed care plans of all description. Rather, its governance, structure, personnel policies and other features would foster a culture of non-profit, publicly-spirited, scientifically-driven medicine.

Business Model Advantages

In addition to the inherent cost efficiency and medical effectiveness of the netorks model of care, there are also many important ancillary advantages to its business model. On the revenue side, these briefly include: Federal Subsidies: Its ability, given the expected prominence of its board and expertise of its staff, to take exceptional advantage of newly available subsidies for Health IT and Accountable Healthcare Organizations. The public purposes served by the adoption of its model of care (which are widely recognized among healthcare policy makers, particularly in the current Administration) would also be an intangible, but important factor in securing government support. Foundation Support: Its ability, for the same reasons, to attract foundation support for its early stage development, and perhaps as well for many of its ongoing operations.

For a fuller discussion of the market failure of the proprietary heath IT industry, and of case for open-source health IT such as VistA, see Phillip Longman, Code Red: How software companies could screw up Obamas healthcare reform, Washington Monthly, July/August 2009. http://www.washingtonmonthly.com/features/2009/0907.longman.html

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State Government Contracts: Its ability to win contracts from state governments by offering the most cost-effective means of satisfying new federal mandates to expand Medicaid eligibility and to otherwise serve medically indigent populations. Federal Research Grants: Its ability, following the example of the VA, to attract federal research grants into the comparative effectiveness of different drugs and procedures, as well as into other areas of key interest to policymakers seeking to bend the healthcare cost curve and improve public health. Low-cost Private Capital: Its access to low-cost, financial capital based on the relative security, liquidity, and tax advantages available to investors who buy the bonds of this revenuegenerating, non-profit institution. The further reduction in financial capital costs likely obtainable through the securitization of government grants and subsidies that the organization can be expected to receive. Venture Capital Support: Its ability to attract political and financial support from venture capital interests as they become cognizant of how its purchasing power and practice patterns can create new markets. These include most notably market opportunities for open-source health IT installation and support, but also for other products particularly associated with its model of care, such as telemedicine devices and medical technology appropriate for home use. Charitable Contributions: Its ability as a qualified 501(c)(3) organization to accept tax-deductible charitable contributions. On the expense side of the ledger, the advantages of the VTHN business model include: Labor Costs: Its comparatively low labor costs, based not just on the inherent efficiency of its model of care, with its emphasis on wellness, primary care, and evidence-based medicine, but on its ability to attract idealistic healthcare professionals who are not in it for the money.

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Brick and Mortar Costs: Its comparatively low brick-and-mortar costs, based not only on its heavy reliance on low-cost clinics and outpatients services, but also on its contractual relationship with affiliated, non-profit provider organizations, who would typically maintain ownership of their own facilities. Procurement Costs: Its savings in procurement costs for drugs, medical devices, and hospital supplies based on its economies of scale and a consequent ability to bypass, as does the VA, monopolistic practices commonly found among Group Purchasing Organizations. Administrative Costs: Its savings in administrative costs deriving from its own underwriting. Non-Profit Status: The advantages to its cost structure that will derive from not having to show a profit. A final sales point will be the scope and integration of the Network, which will rival that of the veterans health system. Regardless of where a member might move throughout the U.S. over the course of a lifetime, or happen to get sick while traveling, he or she would have access to local, Vista-affiliated providers, all of whom would be operating on the same fully integrated health IT platform and patient record system and adhering to common protocols of care. For members of the Facebook generation in particular, the Networks preeminence on the cutting edge of open source health IT would be a major draw.

Refinements to the Delivery Model

For many young healthcare professionals, serving in one of VTHNs affiliated public clinics, community health centers or public hospitals would be an experience akin to joining the Peace Corps, both in its sense of mission and in the freedom it offered from the constraints of commercial enterprise. The Network could also underscore its mission-driven nature by offering service-related benefits, such as assistance with student loans, suitable housing and childcare arrangements, particularly to those accepting hardship assignments in low income or rural areas. VTHN would also appeal to many idealists in medicine by offering a far broader and
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better integrated spectrum of services than does any currently existing managed care organization, aiming eventually to include, for example, on site access to financial, employment, and family counseling. Another point of distinction would be VTHNs affiliation with medical schools, which would be modeled on the practice of the veterans health system. The VTHN would offer partnerships to medical schools that would intimately involve their faculties and students in the day-to-day practice of medicine by making its facilities, in effect, teaching hospitals. VTHN would thus offer its own doctors a far richer intellectual experience than simply practicing cookbook medicine at a typical staff-model HMO. It would offer the opportunity to be engaged in research and to be part of a true learning organization committed to maximizing public health. Because of its effective integration of Health IT and its systems-driven model of care, VTHN would be particularly likely to attract young healthcare professionals interested in new frontiers of medical research, such as using digitalized, population-level data to study comparative outcomes and the social and economic determinates of health.

Key Personnel: Early Stage Development

The New America Foundations Health Policy Program, in partnership with the Washington Monthly and a growing network of actively engaged healthcare policy experts, has taken the lead thus far in developing this proposal. The Health Policy program is under the direction of Dr. Kavita Patel, who recently joined New America after working on healthcare reform for the White House as a deputy under Valarie Jarrett. Also critically involved are three New America fellows: Phillip Longman, who has received widespread attention for his writing on the quality revolution in veterans healthcare and its implications for broader healthcare system delivery reform. The last chapter of his book, Best Care Anywhere, provides an early articulation of the vision behind this proposal, as do key articles he has published in the Washington Monthly, where he is also a fellow, over the last five years.5
Mr. Longman explains the virtues of the VA model of care, and the prospects replicating its performance in the private sector, in this nationally-broadcast television appearance: http://www.c5

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Shannon Brownlee, whose writing has played a key role in communicating the extent and effects of over-treatment in U.S. healthcare. Author of the book, Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, Brownlee is also currently affiliated with The Dartmouth Institute for Health Policy and Clinical Practice, where she is involved in developing and disseminating the findings of the Dartmouth Atlas Project on disparities in practice patterns. Paul Glastris, who in addition to being a New America fellow, is also Editor-in-Chief of the Washington Monthly. In this capacity, he has been critically involved in developing and editing the articles by both Longman and Brownlee that have helped to educate policy elites on the need for delivery system reform. Another key New America colleague is Leif Haase, who as director of New Americas California Program has deep experience in that states healthcare reform efforts, including most recently a critical role in organizing the California Task Force on Affordable Care. He previously served as Senior Program Officer and Healthcare Fellow at The Century Foundation, a public policy research organization based in New York City. Also involved in this project is New America Foundation Vice President for Domestic Policy, Ray Boshara, who is currently active in healthcare reform efforts in Missouri. The New America Foundation does not intend to play a direct role in the operations of the Vista Total Health Network. Rather, it is seeking support that will enable it to use its expertise, contacts and influence to lay a solid foundation for the launch of this new and separate organization. New Americas Health Policy team played a key role in developing the concepts and fostering a national dialogue that led to the landmark Patient Protection and Affordable Care Act. Through its work in Massachusetts, Colorado, and California, it also has broad experience in healthcare reform at the state and local level. It also brings to the table special strengths in
span.org/Watch/Media/2010/05/29/HP/A/33555/Phillip+Longman+New+America+Foundation+Senior+R esearch+Fellow.aspx. Full bios New America personnel involved in the project are found at www.newamerica.net.

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the realm of open-source Health IT, through, for example, its Open Technology Initiative under the direction of Sascha Meinrath. Mr. Longman also has broad contacts among the VistA open-source community, both within the VA and without, including relationships with key leadership at Medsphere and WorldVista. As such, the New America team is exceptionally well positioned to bring together the extremely diverse skills sets needed to lay the groundwork for the launch of the Vista Total Health Network. About the New America Foundation The New America Foundation is an independent, non-profit public policy institute (think tank) that was conceived through the collaborative work of a diverse and intergenerational group of public intellectuals, civic leaders, and business executives. Launched in 1999, the Foundation is guided by President and CEO Steve Coll and an outstanding Board of Directors. New America is headquartered in our nations capital and also has a significant presence in California, the nations largest laboratory of democracy. New America sponsors a wide range of research, published writing, conferences, and events on the most important issues in the nations public discourse. The Organization prides itself on being particularly solutionsdriven. Rather than identify and reevaluate our nations problems (once again), New America produces creative, cutting-edge policy solutions designed to inspire lawmakers to think outside the box. About the New America Healthcare Policy Program Having played a key role in the coming of comprehensive health insurance reform, New Americas Healthcare Policy Program is now focused on delivery system reform. Progress towards universal coverage will be fleeting if the nation does not move immediately to contain costs and improve quality in ways broadly envisioned but only partially built into this last round of national reform. Getting good value for medical spending means purchasing health services of the highest possible quality for the lowest possible cost. It

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also means that the sum total of the purchasing decisions by individuals, employers, insurers and governments must result in a set of outcomes that are consistent with the values of our shared community and that serve to maximize our mental and physical health, our creativity and our productivity. Current Staff: Kavita Patel, director (May 2010-current) Joanne Kenen, Senior Writer (January 2008-current) Meredith Hughes, Program Associate (June 2009current) Allison Levy, Research Associate (September 2009current) Micah Weinberg, Senior Fellow, California Health Policy Program (May 2008-current)

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