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Question: In the new 3.0 system, who are the stakeholders for population health and how do you see population health—growing that box under the 3.0 system?

Halfon: Part of why we've—in that little meeting that I showed you right at the beginning when we were sitting there talking about this—and when I put up this population health versus public health, I thought Lester Breslow was going to get apoplectic. I thought we were going to lose him at that point, you know. And he's like my grandfather in a way, and I was very worried that I had really crossed the line. And part of it is we're using population health as a way of broadening the umbrella of people that might consider themselves part of the health process.

When we say public health, for most people, in the world that I live in in Los Angeles, they'll say, "Oh, that's Jonathan Fielding's stuff. That's the health-department stuff.” And so, when I work with the school health centers and we're doing 3.0 health systems with schools and centers of community health, they're doing population health. They're not part of the public health system. They have no line of authority in public health. They don't even—but they're doing population health. Head Start's doing population health. Workplace health promotion. So, part of what we're trying to do is if we split everything into this bicameral world of medical care and public health, for a lot of people, they don't know where they fit. And so we're trying to create, you know—we're trying to create a bigger umbrella, and then under that umbrella, several tents that other people can be part of so that we can expand the stakeholders and create new leadership cadres, also.

Because if we have a vision for a 3.0 health system and we start to lay out what the design elements are and we start to move it in some areas, we want to bring more and more people into that so we get more leadership not just from the medical sector, public-health sector, but from the other stakeholders that really do have a stake in a healthy community. I mean, when I go and do the health trajectory, developmental trajectory to school boards and I show what that means to them in terms of special education, behavioral problems, mental-health problems, they get it like that and they want to be part of this population-health prevention and promotion. So, it's just a way of sort of changing our discourse a bit and coming up with a—you know, whether it's strategic, we'll see, you know? Whether or not people feel alienated. Because a lot of old public-health people say, "But I do population health. I do everything.”

Question: Hi. Thank you. That was really thought-provoking. And what I'd like to ask is sort of the opposite side of the coin here, and that is as a policy, my first question is always who's ox is getting gored?

Halfon: I'm sorry?

Question: Who's ox is getting gored in the 3.0 system? And if I were an endocrinologist or a cardiologist, you'd be talking about my retirement fund and my kids' college education, because presumably, they're not going to have a lot of business if this happens, right? So, how do you—what changes in the finance and payment system do you need to make to make this work? Because the system's incentives currently are perverse.

Halfon: The issue on this is one of the things that Al Gore brought up right at the beginning when we were starting this process. And what he said—and I think it still serves me as wise counsel—is that this is going to be a long-term process, okay? The endocrinologists now—it's not going to matter much to them. It's not going to change their business model at this point. It's probably over the next 30 or 40 years going to change the business model. Maybe it's not going to change it even half as much as this week on the stock market's going to change things in terms of disruptions.

But what we're doing is really trying to get agreement on what is the health system of the future that we want to get to? What would it look like? What would it be like for you to be able to get these kinds of services in your community, to be connected to this kind of stuff, be able to get certain kinds of health-promotion activities? You know, we can lay out what it would begin to look like, and you can get people from all stripes to agree on a long-term vision. What happens is as you sort of back it up into what we're going to do tomorrow and I'm going to take your money away and give it to—that's when people start, you know—that's when, from a policy standpoint, you have not technical issues, but real policy issues. So, part of what we're trying to do is get the design process so that we get some sense of where we want to go to and start to think about what the—you know, there are going to be winners and losers.

The fact that Victor Fuchs last year sort of came out with a health plan that said, "Well, we need to get rid of all insurance companies,” you know, was a big transition for he and a lot of economists that—and a lot of the insurance companies didn't particularly like that. Just like when we went off on tobacco and said, "Well, the tobacco companies, we're going to go off on them,” they had a way of transitioning their businesses so they've transitioned a lot of their tobacco business into, what is it, Altria, and they now have KRAFT Foods and various other things. So, you know, if, in fact, there's enough lead time for—it's a smoother transition. You can engineer and design for it. It doesn't have to be an abrupt change. So, I don't think you have to go—you don't have to go in the meeting painting bull's-eyes on people, you know, right off the bat to let them know that they're the ones that are going to get gored. I think it maybe is their progeny that might not be in the room.

Question: I'm in the Office of Workforce and Career Development, and I run a division that houses fellowships, and so, along those lines, actually—and this was great. I love the Blue Sky Initiative. The question for me is I'd love if you could expand on your ideas about education, medical education in the work force, because how are we training people to actually practice in this new era and their perspective? Because there's another area—talk about a challenge in terms of changes to medical education, which, obviously, we think are sort of necessary.

Halfon: Well, medical education—we need a new fluxional report, in a sense, for the 3.0 system. And medical education needs to go through a fairly radical change. You know, my—I run several training programs out of our center, and one of the things that we purposely do—and we're very weird and different than most places—is that we have a very strong community-based training component, longitudinal training component, so we give them both a community experience, which is horizontal, understanding what's in the community, and we give them a longitudinal experience so that they can actually sort of see some of the life-course-change stuff that happens.

Because most people are now educated in this very vertical system. And how many of you know that—it's the old Hubel and Wiesel experiments on the development of the visual cortex? Are people familiar with that one? Hubel and Wiesel were plotting the visual cortex. They raised kitties in round rooms where all the visual stimuli were in vertical plains, and the kitties, that's all they saw, was a vertical plain like this. And they took the kitties out of those rooms after seven months and put them into cages where there were bars horizontally. And the kitties walked right into the bars. They couldn't see the bars. And when they went into the complex visual cortical neurons, they didn't have those neurons anymore. It was a "use it or lose it” phenomenon.

In that sense, to me, it's a profound metaphor for what medical education is about, because what we're doing is training people like this, and they go out into the world, and they can't see the horizontal connections. So, thinking that doctors are going to connect stuff up is impossible, because they're like these kitties getting out there. It might be staring them right in the face, and they just don't see it. They don't have the wherewithal. So, we need to go through a profound change, and if, in fact, we're going to move more towards what Ed Wagner and the whole IHI teaming and triple-aim kind of approach, we have to radically change how we're educating folks and moving towards teams and really—and part of that radical change, I think, is going to come not from a top-down process, but it's going to come through new social networking Web 2.0 healthcare programs that are going to be creating communities of patients with inflammatory bowel disease or hemophilia or various other things that are going to be interacting with their doctors in a very different and much more powerful way than ever before. And they're going to be demanding a different kind of interaction.

So I think there's going to be a big demand change that's going to happen. But I agree with you that we have to see a radical change in medical education and education across the health sciences. I teach in a public-health school and in a medical school, and, frankly, I think both paradigms are bankrupt at this point. You know, I mean, public health stuff—we're still teaching kind of the same stuff. Medical school's teaching the same stuff. A few people do the crossover training and they try to integrate it themselves, but we really haven't invented the new curriculum. And I think that that's something that we really need to do.

Dr. Perkins: Any more questions for Neal? Neal, on behalf of all of us at CDC and Emory that's also here, thank you very much for a really thoughtful talk and really appreciate you being here today. And for people that want to talk with Neal, I think we have a few minutes down here in front to answer some other questions. Thank you very much.

Halfon: Thank you.

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