1. “There is no ‘view from nowhere’- knowledge is always situated in a place, time, conditions, practices, and understandings.” Nancy Van House: 2004/40- from Big Data, Little Data, No Data

2. New Payment Systems and You-- the Alphabet Soup Clarified Dr. Bob Morrow

3. overture Do we as professionals need to be paid a bonus to do the right thing?

4. Interrupt QUESTION Cochrane Flodgren Gerd, Eccles Martin P,Shepperd Sasha,Scott Anthony, Parmelli Elena, Beyer Fiona R. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database of Systematic Review. 2011 “We found no evidence that financial incentives can improve patient outcomes.”

5. P4P and the BS Model How does this relate to contracted payments— who has the ownership? What the heck is Value Based Payment? Patient Centered Medical Home—who pays the rent? What is the mysterious Advanced Primary Care? Alternative Payment Models-CMS/CMMI It’s About the DATA, right?

6. Health Systems-Who Owns Them? Financial Oversight—Overlooked? Where does the capital for expansion come from? Are they better than independent practice? Why or why not? It’s about the DATA—right? I don’t plan on discussing ACOs [accountable care organizations] but we can, if you are into attributed lives and magical accounting.

7. Case #1 Your patient arrives last year in the office with an A1C of 8.2. You suggest ways to solve this, he attends an NDPP [ask me], and for six months he has an A1C of 6.2, on life- style changes alone. Does he remain on your registry of patients with diabetes?

8. Case #2 Your 72 y old patient has an LDL of 185, an HDL of 68, and no risk factors for cardiac disease. She is an elite athlete, BMI of 23.5, and a vegan. You discuss lipid lowering strategies including medications. She nods, and refuses medication. Whether you agree or not, her refusal will influence your PQRS score, your p4p, your value based payment, and your gas mileage. Do you reveal that to her as you suggest a drug? [ACC/AHA CV risk=14.9%]