Event ID: 2261610
Event Started: 11/15/2013 8:21:34 AM ET
To the Euratom Dragon the nucleus number just [ Please stand by for realtime captions ] -- [ Please stand by for real time captions ]
Welcome to the meeting today. It's great to have you here today. We are going to go through some housekeeping before the meeting starts. I would say he for we start that today -- the team is going to be change. They wouldn't say I wasn't They wouldn't say I wasn't-- I wasn't thinking about the Affordable Care Act either. First I would just mentioned if -number of councilmembers from the last meeting and so -- the director was speak more to that later during his comments and obviously we do have a new director today. This is on the inaugural her journey first. Welcome. this is and inaugural journey for us. Welcome.
Welcome to staff and others, some in the room and some were viewing us on the webcast. Just a couple of housekeeping notes before we start. If anyone needs transportation after the meeting we ask that you [ indiscernible ] in Antigua by the end of lunch. We all -- we are going to ask that all members meet in the wellness room and Jamie will tell us later exactly where that is.
On the first floor to the right of the cards that. At the beginning of the lunch break for a group for the -- photograph and after the group photo -- numbers will also be this escorted where they may purchase lunch and consumer them private. To the members of the audience if you would like to make a public comment we have time reserved for that please sign up in the anteroom behind me.
People actually now through the introductions of our councilmembers what I will do is I will start off and [ indiscernible ]. My name is Ruth Siegel I'm with America's central hospitals.
I am Jamie Zimmerman.
[ indiscernible ] acting deputy director.
V-letter month worry Mayo C linic.
Carol Medica national press cancel -- national breast-cancer coalition. [ indiscernible ].
Harry [ indiscernible ].
Jeff Thompson Mercer, [ indiscernible ].
[ indiscernible ]. Sandra Decker --
Sherry Lang, payout of home healthcare.
We have Haylee with memory University.
Jane Wyatt pediatric certification board.
[ indiscernible ]
Rick chronic director of AHRQ.
Alan Spitzer
Jane Crowley with Catholic health partners.
Anybody else on the phone?
Hearing none other, our first order of business is to look at the draft minutes from July 26, you should have a copy in your folders and I don't know if there's any request for changes or edits, I assume you've looked at it and if not I would certainly entertain a motion to approve them.
So moved.
Second.
Any comment fix all those in favor fax -- ask -- all those in favor fax
Dr. Chronic was appalled and back in August and I will make a couple comments about him. Obviously a very rich background and understanding how the health system works and how it works for many of those in our communities especially those where most vulnerable. I know many of us had the pleasure of working with him and the assistant secretary of planning and evaluation office and he has extensive background in areas of Medicaid, chip, as chip and the like is actually work in Massachusetts and state government and together still USDA faculty member. He brings that and so much more. Without further ado, Dr. Chronic.
Thank you very much present thank you all for your efforts and support for the agency and tremendously looking for tiered fights and counsel. S% I have have been dark since Labor Day and it's been tremendously exciting -- as proof -- as Bruce has mentioned I have been with AHRQ since Labor Day. Some of my colleagues are with me today and there's a tremendous amount of talent here. I see two main jobs. What in my trying to accomplish. Flux first is to create a clear focus for the agency and a clear message being able to explain to others what we do. We have obviously some folks in the world who is actively maybe don't appreciate the work of the agency but then many friends who are supporters or want to be supporters but when they're asked Tommy what AHRQ does -- when they are asked Tommy what arc -- tell me what AHRQ does and I will try to make it easier. The selling and explaining job but the first part is action figuring out and focusing job. The agency has done great work extremely broad work. A lot of different areas and it was important I think in trying to figure out how to explain what we do have a clear focus that we've had in the past. Share with you very shortly the areas of focus that make sense to me but I'm very interested in your feedback and comments on that that's the first of the two things of what are we trying to a ccomplish. In the second is subsidiary to that equally important that is to develop stronger collaborations with other parts of HHS and folks outside, outside of the government certainly there's been a lot of collaborative work within the agency over the last decade and even longer we are a long way away and we're physically far away from the rest of the government and we have been -- those sorts of collaborations are important to generate that but more fundamentally we need those collaborations to get our it job done. If our job goes to shortly what I see as a mission of the agency and our priorities but broadly speaking our job is to try to make healthcare better. We can't do that by ourselves. We are 300 very talented people and a budget of $400 million and it's very substantial resources and anybody would say it's not nearly enough but it is a substantial resource but in the constant of 2.2 and dollar healthcare 5000 hospitals the 3 million nurses etc. we are very small and we can't change how health care is delivered by ourselves that we need partners and collaborators throughout the government and outside. Our job that will show you on the slide is to be -- is to produce the evidence that is needed to make healthcare safer entire quality and more affordable and more accessible and to work with others to make sure that that evidence -- evidence is is understood in use and it's particularly that second part that we have been doing but need to be focused more on. I want to spend a few minutes and Bruce gave a very kind introduction but a few minutes [ indiscernible ]. Spend some time on mission statement proposed priorities and move into more of an update and kind that you've been accustomed to previous meetings what has the agency doing the plus meaning. Introduction. , political scientist by training. I did my graduate work at University of Rochester. I did a lot of methods work, econometrics and statistics research design and it's a mess and the work there somewhere can social choice theory to move very quickly from being traditional political scientist to working health services within Boston I talked briefly, the best thing about that year as I met the woman who is been my wife the last 13 years. Other than that it wouldn't say much about it but after that year I wanted to stay in Boston because my wife and I got a job at [ indiscernible ] they have a lot of work from what was then CMS and mostly Medicare financing payment policy so the first project was on the second surgical opinion program and we were studying is it good idea for Medicare to pay for second surgical opinions and I did some work on evaluating demonstration to waive the three-day hospitalization requirement that's required in order for Medicare to pay for your stay and did work on the first hospice demonstration evaluation of the hospice demonstration so kind of healthcare financing work that was an introduction to health services and then as Bruce said went to work for the Commonwealth of Massachusetts when Mike Dukakis was governor and spent a couple of years in the office of human services and with staff% to the assistant secretary for health in at the time Massachusetts had an old pair hospital we set system and kind of the main thing that I did it QHS was to work on drafting and generating support for legislation that created a bad debt free care pool and they led many years later, a few years later the healthcare for -- healthcare for all bill that was passed in 1987 but was repealed before it was ever implemented but in some ways many, many years later the health reform that Massachusetts is passing in 2006 and after you HS I worked in the Massachusetts Medicaid program where I was the director policy in reimbursement and we working on implementing Medicaid managed care, trying to improve quality in nursing homes and trying to increase physician payments, 25 years later issues that many Medicaid programs program -- programs are still working on. There was a wonderful job, third best job I ever had. The second one thing the one that asked me [ Laughter ] and in the late '80s moved out to California for family reasons. My wife is a political scientist and got a child -- better job at UC San Diego and we spent a year in follow-up tell on the way out to California where workers [ indiscernible ] at the business school Stanford and we worked on -- Alan is the father one of the parents of the theory of managed competition can you get healthcare to work better the system of having competition among health plans and I worked with him on development of some of that theory and we were proposal for how to get universal coverage within a system of managed competition that was published in the New England Journal in 1989 got some attention and was one of the underpinnings of the health security act the president proposed in 1993 and I've been faculty and the Department of family and prevention medicine at UC San Diego for most of the last 25 years for my work has focused on the causes and consequences of lack of insurance, why do we have more people uninsured now that we used to, either more people uninsured in some places than others, what are the cost of disparities but that also the consequences, what difference does it make that people are uninsured as well as some continuation of the managed competition market structure sorts of work and then a lot of work on various aspects of the Medicaid program some of it around risk adjusted payments to managed-care plans but also ping attention to particularly managed care for people with disabilities and how to make that better and how to improve quality water that oversight structures that Medicaid program should be engaging in. I did spend 18 months in DC in 19939440 on the health [ indiscernible ] at as a staff person working for [ indiscernible ] and the first lady, very exciting time for while and very, very difficult time for quite a long time but I did learn a lot and then came back to DC in January 2010 is Bruce said the deputy assistant secretary the office of the assistant secretary for planning and evaluation at HHS and that was the second best job I had, a really exciting place to be. A lot of work on implementation of the coverage expansion parts of the Affordable Care Act and an early work on the regulations that required dependent coverage of dates, grandfather and other early regulations in 2010 and policy development analysis and then a lot of work on the essential health benefits regulation and analysis of alternative there as well as work on the regulations that are living up to January 1st. A lot of other areas as well, a fair amount of work around Medicare payment policy some of you may have seen it in the notice of proposed rulemaking for physician payment and 2014, CMS has proposed paying for chronic care management services, although not starting until 2015 and that is a proposal that my office work very closely with CMS on. The final had not come out yet. It will be out soon and if it looks anything like the proposed it will be a major transit -- a major advance for primary medical home and pretty big step for Medicare to be paying for non-[ indiscernible ] services. They do a little bit of that now with care management transition from hospital to the community because of the a much bolder and progressive step. We also work with CMS on a variety of other payment issues, hospice Medicare demand two which change this year how their pains Medicare damage plan to try to remove some of the incentives for plans to code more aggressively on diagnoses and the forklift Sherry Lang and colleagues -- and have worked with Sherry Lang and other colleagues and with our colleagues and the MMI particularly around the dual eligible -- eligible demonstrations that [ indiscernible ] and her office had me doing as the evaluation efforts of CMI broad range as well, we did a fair amount of work on workforce issues and particularly how to encourage better use of practitioners and physician assistants and key base care issues as well is the really fascinating and 90 questions about how -- and not take lessons about how our healthcare should be different in the future Ryan Waite and other programs developed at least in part to his help uninsured people. I know there were always be uninsured people but besides that the clients of these purpose -- they will continue to have substantial means. Why do we still have these programs, what should they look like as insurance coverage changes? My office is the quite a lot of work with HSA another health -- HR SA and other health agencies. A very broad range of health [ indiscernible ] there the secretary asked me to be the director at AHRQ and although that was a great job what could be better than heavy the chance to work with colleagues here and try to make sure that this agency is doing the work that is needed to try to make sure that the evidence exists to make healthcare higher quality, safer, more affordable, and more accessible. It's a very exciting time and place to be here and again and look forward to your advice and counsel because I need it as we move forward. This is our proposed new mission statement and how me actually know what the mission statement was? Mission statements don't get a lot of attention. This is not too different from what it was. Our mission statement was to make healthcare more effective. Fairly similar to this, the differences being here our focus is on producing evidence. We are health services agency and I see our job is producing evidence that's needed to make healthcare safer higher quality more accessible more affordable and a little bit difference of emphasis in just making healthcare better and a little bit different the nuance here that was called out accessibility and affordability in areas that we ought to be paying attention to. Obviously important parts of making healthcare better and it that said earlier the other nuance here is a, and to work with HHS and make sure -- it's a bit of a mouthful and it would be nice for mission statements to be one or two phrases but it's important to emphasize as they emphasize the need for the collaborative relationships because if you just produce evidence and it's out there and it's not used it doesn't really help so we need to work with others to make sure that it's there.
Mission statement know one pays attention to no wonder what the old old one once but more importantly what are we going to do and we've got for priorities and are proposing for priorities -- four priorities, we met with the secretary last week she was strongly supportive of these priorities and look for TM put an initiative started by saying that I was out with yesterday and it was obviously pretty difficult they with the president's announcement about change and help individual market plans will be treated. Told her that we would be meeting with you all today and she asked me to pass on to you her thanks and appreciation for your work here. Should've done that at the very beginning but she as I appreciate your efforts. The first priority to produce evidence to make healthcare higher quality and what we are proposing to do is to create a national initiative to use funds from the patient center outcomes trust fund do to have a pretty ambitious initiative to try to disseminate and support implementation of findings and small and medium-size primary care Texas. As we look around the country we see some of the very large physician organizations and places like Kaiser etc. have done a pretty effective job at providing the support that clinicians need to adopt findings to improve outcomes for their patience. It's pretty good heavens evidence particularly and the area of cardiovascular disease were some of these organizations have systems in place that have greatly increased the fraction of patients with high blood pressure control, increase the fraction of patients with high cholesterol were on statins and increased counseling for smoking cessation and aspirin use of them sure you know the department has a large initiative on million hearts campaign to try to improve performance on [ indiscernible ] cholesterol and smoking throughout the country and it's been a particularly vocal problem to make progress with small and medium-sized practices. We don't have the sports needed to do the kinds of work and create how the systems in place to adopt what we know works what we are proposing is an initiative to make Argus there and more broadly to try to provide the supports that will allow the small and medium-size practices to better adapt new findings as they emerge. This is an extension and in some ways of work that we have been doing with support from a trust fund but also a bit of a shift in emphasis in the scope of the object and a large and important part of this is the evaluation. This would potentially be large enough to have a meaningful impact on substantial numbers of practices and their patients. We do not have enough to change the whole healthcare system here. The evaluation. the evaluation part is important and what are the methods in making progress here so that we can then provide that evidence the CMS and other insurers and health systems the sake look, here's what will work to make progress in to move forward. That is the first priority around producing evidence to increase quality of care. The second using evidence to increase safety this woman I think is closest to the work that agency -- this work I think is the closest that we will have success and I think you are all aware the work your colleagues in building A have been doing in reducing hospital acquired infections and tremendous success from the cusp work and toolkits that have been developed and implementing those both through direct support of arc more recently the partnership for patients initiative of CMS and we will be extending that work two additional hospital acquired infections as well as accelerating that work for other kinds of improvements in patient safety reduction in adverse events falls, pressure ulcers, hospital acquired conditions. We have done work that shows the promise in reducing harm from of statistical care and will be working on implementing that more broadly. Work that Tim McDonald has done at the University of Illinois Chicago of communication and resolution programs which shows great promise in reducing medical liability problems and reducing time to resolution and increasing satisfactory -- satisfaction with the process and ultimately reducing harm. We are working on developing a toolkit and testing that toolkit and a group of hospitals to see whether this program and there is a lot of programs as you know when they have a great champion of might work well in one place but the real problem is how transferable are they to other kinds of environments so we will be testing this Friday of hospitals try to see can it be implemented and what are the methods that are useful for implementing it and if we can show that yes, this can work in a variety of settings work and broader national implementation and finally in this area to accelerate patient safety improvements in nursing homes and very promising work that we've been doing reducing false -- reducing false and pressure ulcers in nursing homes in and prep the risk identification and impart through teams that [ indiscernible ] approaches so again developing toolkits and testing and broader implementation so very exciting area and one that is probably one that's most familiar to those of you who know the work of the agency the third area is more different. Bruce talked about change in the third area is proposal to produce evidence needed to increase the accessibility of healthcare in the United States with a particular focus on evaluating the coverage expansion of the Affordable Care Act. We would do this in close collaboration with colleagues in other parts of HHS particularly [ indiscernible ] and CMS the center for consumer information oversight as well as the MCS responsible for them -- implementing Medicaid part of the expansions. In the goal here is to produce evidence that will be useful for the secretary and members of Congress to make better decisions as we move forward and try and figure out how to implement these coverage expansions. This I think we all know the implementation is not going to be static. With Sun example of that yesterday and as we move forward there will be a likelihood of continued needs to improve and change the provisions of the Affordable Care Act as well is the need to make decisions about investments and how to get people to enroll. So the kinds of question's that I think we are looking at here are some the basic ones about what effective coverage expansion have a people set up basic health services question and we know, the first in the easiest one to answer and others would as well is what effect -- do people get covered in that will be fairly easy to figure out with the difficulties that we've been having I am quite confident that millions of additional people will be covered by health insurance over the next number of years. I did once in Massachusetts work for budget director who said never use a number and the date in the same sentence. It's wise advice. I sometimes ignore but I try to remember that the tens of millions of people over some number of years. But then more importantly what affects this has and I think we're quite confident that we will see there will be a big increased -- increase in the number of people who will have care a substantial increase in utilization overall and the more difficult question comes the effects on financial security which again I think we will be able to figure out that it's a bit more nuanced in terms of likely effects. It's very difficult questions of the effects on health outcomes which are obviously much harder to figure out and likely to be longer-term. Any sort of important questions to answer about the effects on labor markets. There's a lot of concern there will be increases in part-time work on the negative side the concern about businesses of 45 not being willing to expand on the positive side a lot of hope that there will be an increase in entrepreneurship and an increase in job mobility and certainly an increase in equity of public financing. It's important for the secretary of Congress and other decision-makers to have as good information as possible about what the effects of this are and that we at arc are well-positioned to do that given the human capital resources we have and the funding that we receive. Also important questions about the effects on competition on healthcare costs growth on essential community providers in can kind of the structure of the marketplace. A variety of really exciting questions here and in some ways made it easier to answer by the unnatural experiment that we've got with have the states not expanding Medicaid which from my point of view a terrible decision and one that I expect will be changed relatively quickly but from the kind of research point of view that's obviously a tremendous opportunity to try to figure out the effects about coverage expansion. I hope very short term opportunity and the one that we need to take advantage of and then the fourth priority -- the fourth priority is to produce evidence around accessibility -- affordability, excuse me and this is also an area where the agency has been doing work -- has been doing work but also I think should be focusing more and clearly the big question is as we move forward and try to make healthcare better is to be able to afford to pay for healthcare. Echelon the lame sure of care expenditures have been growing for most of the last 40 years and about two% two-year more quickly as a rate of growth for the rest of the economy. The patter -- pattern has changed quite dramatically over the last three years, since the last 2010 national health spending has been growing at the rate of growth in the economy so healthcare is a fraction of GDP it's been flat for the last three years and am an even more dramatic change in public programs then private so that Medicare spending per beneficiary when up about 0.5% in 2012 in nominal dollars and inflation of course is around two%, a little over the some Medicare spending for beneficiary when up quite a bit less quickly than general inflation that follows 2010 and 2011 where that affair should -- beneficiary when up about the rate of inflation there's a lot of uncertainty about exactly why Apple discontinue or not, both the office of the actuary at CMS and the Congressional budget office can project over the next decade that Medicare spending will grow per beneficiary at about the rate of growth of the economy. Projections are fraught with uncertainty but for what it's worth they are projecting that figuring out how to get there and how to have and how to use resource as well is one of the fundamental challenges to making healthcare better and making it higher quality and safer and we need to use how to use -- we need to learn how to use resource as well. I would say in this priority more so in the other three working progress on all of these I'm late your device and counsel on this one particularly trend figure out what the investments are that are likely to produce useful evidence is a scenario where I look for health. One specific initiative. Would be to work with our colleagues at [ indiscernible ] who recently and more importantly awarded about $90 million in grants to states to support [ indiscernible ] activities but a big part of those grants were to support state working with their data centers and in many cases all data. Databases and other data centers within the state to produce information about the prices that hospitals and physicians receive from various insurers pick those states are in various stages of being able to do that. We have worked with the old pair -- all payer groups from any used -- many years now and will provide technical assistance and support for those efforts. More broadly we're working on tran2 figure out whether we can make progress being able to provide evidence about how resources are used in various health systems around the United States and that relationship [ indiscernible ] quality. Some of this builds on the kind of work that was done and has been done by Jack [ indiscernible ] and his Dartmouth College -- colleagues for the last 30 years and a tremendous amount of value that, the understanding that variations across regions and how resources are used but regions don't make decisions about resources. Health systems and clinicians within them make decisions and are kind of actionable units on resource use and we don't have information at this point about resource use within health systems. We all know been told public at least 30 times if not more and less 3.5 years that guys and there is a high-performing health systems and I'm quite willing to believe that but there isn't actually much evidence to show that because we don't have methods of being able to versus the buying health systems and describing relative resource use and try to understand what are the characteristics of systems that use resources -- more resources than fewer and again quite crucially the relationship of that to the quality outcomes of care that's produced and so investing in this area more broadly investing in and producing evidence that well lead to improvements in affordability and efficiency is an important priority for the agency. It's kind of a brief overview of the four priorities I'm proposing for the agency. I got one more slide on budget and then invite your questions and reactions and feedback and that we will move into the update of what we've been doing over the last four months since you last meeting their kids I'm sure you're all know the government is functioning again following the shutdown on a continuing resolution to the middle of January and the continuing resolution has [ indiscernible ] funded for FY 14 base $465 million which is a combination of 365 from the public health source evaluation fund and $100 million from the PCOR trust fund obviously to the middle of January it's a committee working with the December deadline to try to figure out what to do. I'm not going to speculate on what might have been -- happened but we know we are on SCR two January 15th and the priorities that I've described, we are proposing to support within the context of CR in part by some reallocation within the portfolios and program support budget. And very excited about this direction for the agency and trying to create focus on these four priorities but I look forward to your advice and counsel. There -- we will stop there and ask you questions and comments.
Thank you very much. We are very appreciative of your transition -- transparency and setting forth a mission statement in priorities and clearly at the outset of going to make a comment and turned to my colleagues here for their comments and questions in my comment is I would urge you as you look at these priorities to continue to explicitly think about issues of equity and health equity across them all for four of them have implications in those areas and I think it will be do not explicitly think about equity we forget about equity and then we're surprised that the outcomes we get are desperate and wonder how that that happened so as if we think about Jack Lindberg's work on variations and they exist in a vacuum. That continues to drive health,-- health outcomes the medically even here and Mike break -- Montgomery County we can see the outcomes which are by geography so I hope that that will continue to be a recurring theme -- seem. There's so much -- recurring theme and there's so much to be done in the promise to address some of these issues we hope that that work continues.
I appreciate that comment and it serves we've now. I think as we look through each of these four priority areas it will be front and center as we think about improving quality and particularly for people who are disadvantaged is clearly a very important part of improving quality overall and safety issues are as you know from your membership even more difficult to tackle and places where there are bigger challenges to begin with on accessibility agenda that is most explicitly around equity issues and affordability so thank you for that reminder.
Thank you. I'm going to move this week around the table and I know a lot of cards are up. I will start with Victor to begin.
In queue very much, director, for that exciting vision. One of the things that I think has changed or perhaps was always there but I think it's changed over the last five years is that when one looks at the outcomes of the healthcare system one begins to look at it carefully through the eyes of the patient and particularly as patients accumulate multiple chronic conditions, it becomes necessary to understand the impact of the healthcare system. As a look at the realized mission statement and the priorities, patient centeredness is embedded -- embedded in the quality component but it's concerned about equity being embedded in their patient centeredness doesn't get called out and it does have implications for instance about some of the value judgments about in [ indiscernible ] efficiencies are value. You mentioned overutilization, the traditional way of thinking about it is when you do more than what the evidence calls for but the evidence alone never tells you what to do there's value the presence -- preferences and also the context of the patient if people have an indication for something and they wanted but they cannot fomented but you push it on them and also waste and overuse it it's not called out and he thinks -- I think it's such a fundamental way of thinking about healthcare systems through the integrated as of the patient and the fact that patient centeredness is only mentioned in the name of [ indiscernible ] seems like something that if you were just to add this it would bring it -- the whole constituency that can be [ indiscernible ] on your new vision.
Thank you for that comment. Patient centered is obviously a crucial part of making healthcare better, better for who? For patients and I guess I look forward to your advice and counsel and how to integrate that into the work that we are doing. As you point out on the quality part and crucial parts and on the resource use part. I think as we look across help systems and try to understand the differences and how resources are used that we are likely to find an important part of the differences in the involvement of patients in decision-making and certainly is vital to being -- [ indiscernible ].
I like the changes in the mission statement. They make sense. Thank you for that. One thing I want want to pylon to what Bruce said, I really agree that one of the hopeful things about the ACH is that it will improve that ace -- disparities. Ernie's team has worked so long and hard to have this unfortunately not well disseminated it seems like an opportunity to use that as a platform with the other skills to articulate with the ACA has done to hopefully narrow the disparities in those bite income and race and other features. The question I have is ending the fourth priority weeks a lot of sense. It's a little bit dicey because it reminds us of some other work that the mother agencies are charged with and what can make it special is the following. The dialogue in the 90s with it issue of capitation and that potential intrinsic hardship on the provider take some insurance role and the obvious financial benefits but also potentially the risks and of course it was redressed announce carbon it Seo we call other things are bundling. I don't disagree at all that those things have to be done to get things to work however the danger is in fact of the patient in their family and it would be really special pull that we could work and I think it would also for a church you to work that would put I think and a very favorable light while still looking at the economics to understand potential risks and benefits at the patient level of bundling and this insurance shift. It's potentially dangerous and obviously we all understand is most simply put in capitation and if you have had a lawyer that that this is how much of what the charge you and I'll see how much I'm going to spend for you. If we all know that has to happen and a fee-for-service system is pernicious -- pernicious hope that will be a focus area.
I appreciate the suggestions and I think implicit in your suggestion and the for the area is kind of the age-old question that will be with us I'm sure forever which is the search for accountability mechanisms and the kind of rush towards value based purchasing quality measurement is one direction of searching for accountability, possible care organizations and we have accountability in the name there is another related method and I'm sure with ministers from Commonwealth fund and everywhere in the world as a question of accountability mechanisms and health care work well for the patient's. I do think that is something that the agency can contribute well to -- well to so thank you for that comment. Jeffrey? I'm sad that I'm leaving but I will watch from afar in the other Washington. I'm excited about these and I want to thank you for putting [ indiscernible ] CMS is Medicaid. Now that you doing OB I think is phenomenal. Medicaid pays for 50% of delivery so it's great that we are f inally -- the only thing that I would add is that would be nice to hear more about employer health care. Everything seems to be about Medicaid or healthcare -- Medicare and I think employer-based is something we need to know especially where we are going with the public exchanges and how this will effect on employee maintains their job on employer actually makes decisions on products has healthcare is a huge expenditure for employer so a more of visits on the employer side is all I would ask.
They give for that comment.
Employment-based health insurance is going away. You didn't get the memo yet. [ Laughter ]
You don't have to respond to it.
Apology in advance because 1120 a need to leave for a few minutes -- 11:20 a.m. because I need to leave and an answer questions about employer-based insurance. Andrea?
Thank you for your comments.
Thank you. I'm glad to are here.
I think we have to focus on availability and sustainability and the effective ways to really sustain the project once our funding ended in a think about project read and it certainly seminal work and reengineering [ indiscernible ] but they got those outcomes [ Indiscernible -- low audio ].
How do we do sustain results. Switch topics of evidence, good evidence we need to find a way.
I agree with you completely I missing part of the mission statement and make sure the evidence is understood and used and the poster child of success here is the work that we've done making healthcare safer and which we've developed evidence and have spread that evidence in part through our own activities and impart to the collaboration with CMS from partnership for patients was that evidence has been spread and we need to work on expanding that model into other areas.
Rick, you guys have made great progress with the mission and priority areas and I just want to build a little bit on what Victor was talking about and as you know there's been a small group of us that have been thinking about the same kinds of issues and I guess the way that I sort of thought about this has been using an organizational framework that was developed by [ indiscernible ] where it's got the physician and the patient at the center and then moving out from the physician is the practice team and the healthcare delivery system and I think your priorities have that part of it. The part that I think you could build on his the right side of the patient we've got the patient and their families because you can have a perfect left side of the system and if you really don't address the right side of the system you're not going to help patient outcomes and addressing things like Tatian the engagement. That would be my only suggestion is just to consider the patient factors.
Again. Appreciate that and the next agenda item is just discuss the [ indiscernible ] recommendations and we look forward to that discussion and your price about how to actually operationalize that n otion. Michael?
Thank you. Particular break in the mission having finished with evidence and used but it really appreciate that particular language and agri- with much of what's been commented on here and I'm excited about the conversation related to what the [ indiscernible ] put together there is definitely overlap but there are some places where I think we are right -- recommending they fill in places that may be missing here. Appreciate the opportunity and I will make a couple of comments to add to the discussion people and places. A priority number one, this conversations particularly around primary care practices. As a physical therapist I want to put in a plug for how are we helping other providers so that they are doing it better and safer and I know that's not meant to be excluded but it feels like it but it and also the language that I hear here and other places. One additional piece of that is because the language in this document and others continues to be very disease centric and again I'm clearly biased as a therapist but where is the focus on function because yes I want my heart failure managed what I really want is to get my grandson baseball game and so for talking about patients and families functions and disease need to go hand-in-hand if we recognize that is a focus that would be helpful. As far as places and priority to it talks about half those in nursing homes and nursing homes and priority for doesn't talk about specifically any place the would like to put the patient for places outside the four walls of institutions that which does include primary for care physician practices but also OB services assisted living please where people actually living in and a good portion of care is delivered. Some additional thought conversation about that and I just wanted to edit at this point and overall I appreciate the work and thank you.
I appreciate those comments and priority one does say practices that physicians so it's explicit and priority to we had actually six bullets on their one point which was around ambulatory care we took that off because it's less well developed and less sure we can actually produce their but we are investing and have invested will continue to invest in work attire in the first figure out how to actually define and measure diagnostic -- diagnostic errors which I think is the key part of errors in ambulatory care but also doing work and medication safety and others. Your comment that we need to be outside of the four walls is certainly exactly right. As you know it's much harder the promise of these prairies in part of things that we feel more comfortable getting closer to promising although some of this is part in part aspirational.
Gene?
Welcome. It's good to have you here. I work with the public in the patient on this Council and I love the fact that you are talking about infection reporting. It was after 26 individual states passed legislation that we really begin to see traction the fact is that it was public access to information that was driven some really important work so I think that is important for us to keep getting the facts out to the public and help them better informed as we are spending more money as an individual we need better information so I like that and all the work you did on your mission. The other thing as I sit on our state a CPD and now we're we're going to have access the data we have never had before. Your parking with the states around a TCT data and the better use of that data could be really an exciting opportunity for the residents and all the participating states. All the states are worried about sustainability of setting up all the structure of wondering how are going to keep it moving when information will be invaluable to the patient. I just finished my third [ indiscernible ] review and as a reviewer and no one is talking about the culture of patient s afety, a culture of quality and I'm looking for a two-week really address that whether it's to medical schools are going to continue to be disease specific recommendations as well as loved everything you said, I came to this thing medical liability reform which seemed to sort of land from another planet into a very well thought out and I'm not sure where that came from.
Thank you for your comments medical liability reform in particular it comes out of work that we have been doing attend figure out how to reduce errors in hospitals and how to reduce harm that is done patients and also how to make the process of resolving in getting compensation the patient's mother is harm more efficient and less contingent and that are all around so we have supported a variety of progress -- projects to try and figure that out in a number of them have shown a pretty successful results building on the kind of communication and resolution approach where hospitals are honest with patients and say you know what, we made a mistake here kind of do that early on. Medical liability reform and some people mean capping pain and suffering. That's not what talking about here.
We're talking about improving communication.
Yes.
I would just add to that that within hospitals this reduction of risks is so integral to their safety agenda and part and parcel but at the same time we often say this we see incredible outcomes cleaned, I'm not sure we really know if they are empathy evidences behind us.
Chris?
Thank you, Bruce. If folks could speak into the microphone it would be helpful for audience.
I join with others in welcoming you and also congratulating you on the clarity and timeliness of the new mission in the new priorities for the agency. I am especially delighted to see number four and like the previous speaker our state has an old player things database and it's different from any of the others around the country and that it is voluntary. It's not tethered the state government. It's a 501(c)(3) organization and as we started to assess how we can leverage that new data tools in the area of efficiency and cost and resource use this to obstacles that see that perhaps the agency can be helpful with. 1 I think it's probably more resolvable at a local level and that's that the traditional reluctance of both appears in the providers to disclose allowed amounts which get more accurate assessment of costs and I think there's momentum to begin to change the trajectory of that traditional relo that's as a result of the [ indiscernible ] article and other initiatives at a national level. But the more vexing problem for us is the restrictions in the Affordable Care Act on these the Medicare data. While on the one hand it's a longshot objective to have access to part by data to integrate with commercial and other public-sector payers, the provisions of the Affordable Care Act are contradictory to the sustainability of especially a voluntary all claims database and there is no mechanism by which we can generate revenue to sustain a volunteer initiative under the of for -- under full under the Affordable Care Act that data can only be used for transition of physician performance in the and need to be available at no charge but more importantly the data cannot be released to subscribers for unfettered analytics which is where the real potential of the Medicare data rest. There some concerted efforts underway on the part of up group of stakeholders to try to introduce language that would create more permissive uses of the data but perhaps the agency can be useful and helpful and that effort as well to unleash the power of Medicare data and ways that are not possible right now under the language of the ACA.
The administration and the president of the White house strongly supportive of open data initiatives and a recognize the continued difficulties in access the data. We have a think made a substantial progress it certainly CMS is now pregnant and other folks there have been working very hard to make data more available and more easily available within the confines of the statute that we have. There's a lot of interest obviously -- you know as of competing concerns about privacy need to be dealt with but there are probably ways to make further progress.
Thank you. Beto David you just joined us. If you want to introduce yourself everybody briefly.
Sorry to be late. Any myths David Evans and member neurologist from [ indiscernible ] University.
Is anybody else who is not introduce themselves? Not hearing any please go ahead.
Thank you all for your helpful comments which I take to heart and will work on incorporating anything particularly the comments around equity are mostly of framing questions and here and dear to my heart and also our central to the agency -- the agency's work in the variety of comments on patient engagement I think are really crucial and I look forward to excise and counsel on how to take those comments and exactly what to do with them in terms of the work that we do. We look forward to continue the discussion there. I would like to thank those of you for whom this is your last meeting and go through some of the wonderfully been doing and tell you about the funding announcement that have gone on the door since your last meeting, the work we've been doing with safety quality area and in some data here and accessibility and affordability and directions with some of the products so first many things to retiring members. [ indiscernible ], [ indiscernible ], I speak for Mike Howley and for Caroline is and thinks for the work that you have done the beneficiary of it [ indiscernible ] thank you very much is and I don't everybody has a lot of work to do in their day jobs and we need and appreciate your advice and/or support for the agency. Thank you for those of you who are leaving and I hope I can continue to call and in you even if not in this forum. We have been active and releasing funding opportunity announcements these are the announcements that are released in FY 14, third, that are sponsored with PCOR trust fund dollars for FY '14 on the left-hand side and on the right-hand side that are sponsored was appropriated public health service funds. These are all announcements that are out on the street and I'm not going to read through all of them tick if you have questions about any of them come up please do ask my colleagues here in the audience will provide the answers. The release before he got here and I don't want very much about them.
I think that we need to make a clarification. Can you go back one slide. I'm sorry, the first one on the left side is co- funded. It's funded actually by [ indiscernible ] not the PCOR trust fund. Thank you, Jean and Joe Salvi who was that director of [ indiscernible ] will be here shortly and one of the challenges and opportunities facing the agency and [ indiscernible ] for explaining what our respective functions are and also more importantly figuring out how to work together synergistically which we've been making very good progress on in his team points out [ indiscernible ] is funded by Corey but funded families from it's are queue thank you, Jean.
In the safety area we have just released a toolkit, step-by-step instructions for improving tracking reporting and following up on lab test results they think many of you know patients go to physicians offices, Pickett lab tests done in laboratories results don't get communicated clearly, timely, their loss or something happens and we have developed a toolkit to provide straightforward advice and methods for tran2 makes this process better and we've done this collaboration with partners and continuing to promote the tooltip without reach the several dozen natural organizations and federal partners, Twitter messaging and of coping -- upcoming articles of the November newsletter of national Association of health care quality and Academy health and this toolkit has been quite favorably received in early goings. We have continued and are strengthening the work on comp rate heads of unit based safety program, the cusp program. That early work on this issue no was central line infections and we have been working on catheter associated urinary tract infections with very impressive and heartening results in the 14 months of our 16% reduction in [ indiscernible ] and as many of you know urinary tract infection is much board difficult to deal with an essential line line infections. The centerline they are all in the ICU pretty much and much more and much easier to get a focused attention on catheter associated urinary tract infections, harder to make progress and this is a very exciting demonstration of progress working on extending this to a surgical site infection both in hospitals and amatory and we just initiated work on [ indiscernible ] associated pneumonia and [ indiscernible ] and long. Facilities so very exciting work in these areas. We released in September a report on health IT enabled quality measurement and this is the second to last report from these efforts and as reported in a fight how health IT enabled quality measurement could be proved by future research. The report is part of the health IT portfolios scanning activities and builds on environmental scan of current activities and initiatives on a public request of information on focus groups and work with key stakeholders. We offers discussion of spit -- stakeholder perspectives as well as the practical guide on how to enhance infrastructure in ways that can provide short-term benefit to the quality improvement enterprise. Clearly there's been tremendous investment in health IT from high-tech and the Affordable Care Act figuring out how to not just check the box on meaningful use but actually have to have help IT contribute in an organic way to quality improvement and quality measurement is kind of a next frontier in this report moves in the direction of tran2 get to and beyond that frontier is whether -- as well as other work that John White and the other health IT portfolio are doing. And then we also or assumed to be releasing a how to guide for health assessment and primary care as you likely no the Affordable Care Act make the health assessment part of Medicare annual wellness visit and there's been a lot of other encouragements for physicians to provide health assessment but then the question is what is that? Cited do it there's a lot of health assessments around and this is a guide to try to help providers make some sense of the space help to figure out kind of which health assessment to use and how to implement one successfully. The preventive services task force recently released it's 2013 report to Congress on gaps in evidence in the report highlights the five areas where we don't no enough about what works and what doesn't work. Screening for cognitive impairment and dementia, screening for physical and mental well-being, commending false and fractures, screening for vision and hearing problems and avoiding unintended harms of medical procedures and testing. So each of these are areas that the task for -- the task force considers systematic reviews in evidence and would really benefit collectively from better evidence and colleagues at an age and other places look at these reports and Corey, to try to figure out where it makes sense for them to be investing in trying to introduce better evidence. It's a very interesting report for those of you that haven't seen it the evidence-based practice Center can treat -- continue to be extremely active in producing axis to medical reviews and methods reports and there is [ indiscernible ] him not going go through the whole list but I'm happy to answer questions actually do for questions the gene if you have questions. Electronic data methods form continues to be active we will continue to support the form for the work and data analytics and clinical informatics, a variety of work coming out of the work, to supplements and medical care, special issue of evidence generating evidence of methods or electronic E generating evidence and methods to improve patient outcomes and other papers in activity here. I'd like to provide a brief report on the subcommittee on child core quality measures, we have two to s nacks. No coffee and no food and to thank the members of the snack including particular and it gets -- Andrea Gelt served with it [ indiscernible ] member and the snack was charged with conserving which of the 20 court set measures in the core sets that was adopted in 2009 which if any of them should be retired and they've had a variety of meanings first to agree on the criteria for how should we decide which measures should be retired and have scored them and made wreck -- made a recommendation of three measures and that's not public yet about which of the three measures. Out of you want us anymore about this?
I would just say that a couple of observations, the first one I was very surprised about the apostasy of evidence supporting not just measures but ultimately were recommended for being retired but all measures and secondly t he second -- the ones that were recommended for retirement there is pretty striking agreement into which ones those measures should be.
So when you say apostasy, the use of these measures will result in the improvements and qualities.
Couple of updates one from [ indiscernible ] cost utilization project and annual report on the top five most expensive conditions treated in US hospitals and you can see them listed in this slide and complications of device deliveries and analyze. These five conditions accounted for about over $70 billion of spending in 2011, about 20% of all of the cost to inpatient care and [ indiscernible ] is been [ indiscernible ] has been working pretty accurately with a million hugs with preventing data on inch -- incidence of heart attacks for 2010 and 2011. And the complete 2012 data for subset of states and [ indiscernible ] has also been working on speeding up the release of data with that 10 or so say -- states as part of an early release project where they provide data for quickly than the usual annual basis and we are trying to generate estimates based on the quarterly submissions and make quick progress on speeding up date of release there. A couple of [ indiscernible ] products to discuss. One some work that [ indiscernible ] and colleagues have been doing and Bruce mentioned earlier -- not mentioned but told us we need to be always paying attention to equity in this project is kind of front and center there and that the workfare was focused on discrediting the distribution of public spending and healthcare and I will show you the slides from it so this slide shows that per person public spending in healthcare averaged a little over 3300 or $3400 and 2007 and so the bar on the left shows the distribution that public spending, type of spending and you could see the bottom there is Medicaid and a little under 1 quarter of total public spending, the red bar is Medicare, a little over quarter of spending, other is a grab bag of -- of federal and state and local committees that the VA and other things in there and then the tax expenditure is the public spending that the treasury makes on our health insurance which sure you y'all know and everybody in here has employer-sponsored insurance. Our employer-sponsored insurance, will we get attribute to the into the year, our W-2 income doesn't show the value of the compensation that we've received from our employers that received in the form of health insurance and the caps expenditure is a measure of the foregoing Texas that the treasury just up by the fact that our health insurance is tax preferred and you can see that that tax expenditure accounts for about 1 quarter of the total and the rest of the slide shows the distribution of expenditures.
Age and not surprisingly and sensibly the elderly that [ indiscernible ] beneficiaries of this -- with Medicare content for not quite all of that and I think from the board interest is the distribution of what this spending looks like bike and from -- by income group and [ indiscernible ] we saw in the last graph for everybody and you can see here expenditures were people who were below the poverty level are of little over $5000 a year with close to half of that coming from Medicaid and substantial from Medicare as well and the other grab bag/other but expenditures for people of 400% of poverty and above are about $300,000 a year with a big part of that being the tax manager and Tom and colleagues are working on tried to figure out how this will be different in 2014 and beyond. That sort of striking thing about this graph the means at least the relative flatness of it. There's more expenditure on folks below 100% of poverty than folks above 100% of poverty the grading is not all that steep and it will be super after 2014 and I don't yet know how much steeper and then very much looking forward to seeing those results and I think this will be very useful for folks to kind of figure out policy moving forward. And the last slide and I will open up for questions is work that Steve Cohen and colleagues did on the concentration of expenditures pointing out that one% of the population on home the highest amount of spending is made account for about 21% expenditures in 2010 and is picked up among other places but the Washington Post who did this nice graphic about it and the one% solution tran a guest to build on baby the 99% occupied issue. But very interesting work from Steve and [ indiscernible ]. There, slightly shorter drifters update. I look forward to questions and comments.
Great. Thank you very much. I think brevity will be welcome and we appreciate the fifth there. He also covered a fair amount of ground and I'm going to turn first to my colleagues to see if they have questions or comments. Andrea it looked like you started to raise your hand.
Now. no.
You left them speechless. This is new. Hearing now commentary whether we do the following first about I think people with very much appreciate -- I think that is something that we are all eager to have an appreciative of having and thank you for that thank you for being so straightforward on some of those issues. Now that later this morning we're going to be having an update on our subject on strategic direction and I think Michael and Helen will presenting that the that framework and are be more active discussions on that and expect that will provoke a fair amount of discussion here as well and that will be followed by public comment. -your schedule and the fact that we really much went to make sure you are in the room for both the discussion, direction and public comment but I propose now if we take a break and that will keep us early in ensure your availability the why don't we assume will take about 15 minutes break and reconvene at 10:25 a.m. sharp. Does that make sense, Jamie? That will put us about 20 minutes ahead of schedule. Right? It's -- we will have to make sure Helen is available. For now but you assume will reconvene at 1025.
Before we do that, link -- but we think Mr. Mirman for the work she is done in making this meeting possible.
-- -- I think Ms. Zimmerman for the work she has done in making this meeting possible[ Event on 15 minute break -- will.
[ Event on 15 minute break -- will reconvene at 10:25 A.M. EST -- please stand by ][ Captioners transitioning, please stand by ] [ Event is on recess. Captioner standing by. ]Will ask you to introduce yourself and then we will get going. We will just wait another minute. I think we have a few folks out in the hallway still. We want them to be here for this presentation.
All right we are going to get started now. And we have a couple of items before our lunch break as we reconvene now for two important items. But before we start another we have been joined by one of our NAC members , Sarah night. Welcome. If you could tell us a little bit about yourselves for our audience.
Graphic. Thank you very much. I am sorry night the Department of veteran affairs and the deputy director of health research. I'm covering for David Atkins who regrets that he is unable to be here today. Thank you.
Great. Thank you very much and thank you for speaking into the microphone to. That's a little bit of a challenge and we hope everybody does that. So this point we have an update from our subcommittee on strategic direction. Another cochairs Michael Johnson and Helen Haskell is a formal NAC member has led this effort over the past few months and have engaged many of you who also served on the subcommittee and a lengthy and important discussion. So first of all which is want to thank everybody on the subcommittee and especially as cochairs for what was a lot of hard work and I could see that.
At this point I'm going to turn it over to Michael. Helen are you on the phone?
I am.
Great Helen. Welcome. I'm going to turn it over to Michael to lead us off on a discussion.
So actually I will in turn turn it over to Helen who get started and then I will finish and then we will open the floor for discussions. Helen you are up.
Okay. I cannot see if you all have the slide up yet that
Helen we are going to bring it up in a second here. If you want to wait just a second. I don't know if you have met the new director you are not so if you like to start of introducing yourself briefly and your perspective, that may be helpful as well. So just give us a minute what we bring the slide up here.
Okay. I am Helen Haskell, mothers against medical ever and consumers of patient safety and I'm a former NAC member. And last summer Bruce asked Mike and me to cochair this subcommittee on strategic direction. And I just wanted to thank everyone for all of the hard work they have put into this and a compressed period of time. And then the subcommittee was requested by the NAC chair during the Apple 2013 meeting and the goal of the subcommittee is to revise the NAC on leadership and future direction and priorities the reason that was created was because of the fiscal climate and the attending leadership change. That is with the current and past NAC members. So at our initial meeting the NAC members discussed a number of topics including the proper niche for art and the art audiences and how to continue the value. And we all agreed that this is an essential agency. Predicted time limitations and the government shutdown it also becomes part of what will focus its efforts more on the general agency rather than how.
So this led to the development of the strategic framework that we are presuming today for consideration. I don't know if this slide is up yet.
It is up now.
Okay. This framework reflects the view of the members and it is broader and a little more differently focused than the mission statement presented earlier by Dr. Koenig. So obviously it is in no way binding on the agency. So we just wanted to present this for discussion and possible adoption by the group. So this is with the group considered our focus and the advancing health services research informs patients and clinicians and providers and payers and purchasers and public policymakers and the Department of Health and Human Services and other parts of the federal government I wasted fans the health skills of individuals in their come unity.
The next recommendation for the goal for where our research should focus on overall health system performance and collaboration with others. In ways that engage patients and families and communities to advance the health goals. To focus on quality with a particular emphasis on patient safety, and hands the affordability of healthcare and promote the translation with the patient centered practice. I will now turn it over to Mike will provide for the details and lead with the discussion.
Thank you Alan. I don't want to miss the opportunity on behalf of Helen and myself to think the members for the active engagement to the process. I would also be remiss if I didn't take think Karen and Jamie were tremendous support. I have heard Bruce and Rick say it and Carolyn all the time but you don't realize it until you have the opportunity to experience it so Thank you very much. So what you have in front of you the framework represents our efforts to provide a broad strategic effort which is you know occurred in parallel with the leadership to clarify the reasons and priorities which we talked about this morning. So the group believed was important to recognize the essential role with ways that meaningfully impact and improve decisions we all Mike about health and health care. We believe that this should have discrete actions to improve health and wider processes of care and then those families who seek care and their individual health goals, we believe that the thing engagement inpatient safety and enhanced value and translation for putting evidence into practice is important and unique to the role with individuals and communities across the country. So that said, given the work we have done today tended to some kind time constraints and the government shutdown in the time we have left we would like to suggest a subcommittee for six months with the final report back at our April meeting. We believe the extension will allow the group time on additional clarity on how IRC could or should have key issues such as patient engagement as well as evidence translation or in other words turning what we know and what we do every day to improve health and figuring out how to operationalize and systematize that into the work that a RC does. With that said it in the back to the chair and look forward to discussion.
Thank you Michael and thanks again to all of the volunteers who work so hard. I will be asking for those of you around the table to provide your input for this. Because should we recommend this to the director at this point is a recommendation and understand that we will be refining it over the next six month period? I ask it is to study this and think about it and provide your commentary. I have a couple of initial comments. When we look at the framework you have developed and the priorities which the director articulated, I feel a lot of synergy. I see a lot of alignment. I have two comments. One is that the priorities clearly responsive to the bureaucratic framework and with the ways that it should which is probably that you may want to necessarily. And with the implementation of these parties which I think is something more for the agency necessarily the more for us as part of this process. The only thing I would also say as to other comments is the engagement of patient families and communities is very exciting. I think it will be great to further elaborate on that. And again, just the equity issue that is a theme that can be seen all to the priorities and the question is how do really make that real and explicit work perhaps I can be helpful for that happening. Certainly to talk about the million hearts campaign for instance that area were hopefully those values can be brought to bear and very operational ways.
The last comment I will make is the ACA is called a very explicitly which this framework does not this is understandable and also think this framework is a mature height of the overall health system performance today and is for elements of the framework without getting into the heart of the ACA which whatever happens yesterday and happens to mile is changing healthcare dramatically and rapidly in ways that we don't understand at all. So just a few preface comments we wanted to make an op open it up from commentary from our NAC members.
I know that many of you served on the NAC be curious to get your discussion as well as other comments or impressions that you have at this point.
Thank you. I just want to add my thanks to Michael and Helen for their leadership on this effort and you are very active and vocal group in our efforts. So I would just address your issue first on the ACA and then and then the topic of the ACA came up as a point of discussion as to how directly did we want to sit that in the goals and the mission. I think it was generally the feeling that the consensus was that the ACA is to be included in any evaluation. But that it would have much broader appeal and that the agency would have much broader appeal if it was not seen so closely aligned with a particular action. But certainly ACA is law and it is what is and it is expected to have a huge impact and hopefully a very positive impact on the care and the way it is delivered.
The other thing was, if we really, I think the driving topic in our discussions or the driving issue in the discussions was always about patient centeredness. And it really drove us in a way that was the prism through which we looked at all of their topics. And issues there. So while I can appreciate that is included in your mission statement, and by the way I think your mission statement is fabulous. That in the goals, we felt that the patient centeredness and the patient had to be called out and had to appear if this was going to be an effort. All done all parties. So many times patients feel excluded from the process. Even the patient engagement process feels onerous or burdensome to many patients. So by building bridges, by calling and all parties to be part of this, given that all of health outcomes are patient centered. It is about life or death. It is about quality of life. All outcomes, by definition have to be patient centered ultimately.
So I just want to put in and emphasize are strong feeling about the need to have patient centeredness included in the mission and the goals.
I will address both parts of that. On the affordable care act, clearly there are some risks for the agency in saying that we are going to spend energy in evaluating the coverage expansions and other parts of the affordable care act. It is no secret that the affordable care act is a highly partisan piece of legislation. It has kind of the Phoenix or perils of Pauline and Allie and I'm not sure which is more appropriate but I think probably the perils of Pauline with the train approaching and some housekeeping just before it gets there.
Obviously, there are some folks in the house 12 once voted 20 us out work and potentially if we say that we are putting effort into try to evaluate the effects of the expansion that it provides more recent effort for people who may be inclined to think that to begin with. And on the other side, there are dangers and even likelihood that we will produce some results that my boss, the secretary, is not going to be so happy with. And so I am aware of the risks involved in saying that this is something that the agency should do. There is some risk that the statute has the stature to evaluate work and this is to move forward. Having said that, Asbury said, this is the largest change and how we finance and deliver healthcare to American population since 1965. That the job of this agencies to produce evidence that is needed to make healthcare higher quality and safer more affordable and more accessible, I don't see how we could possibly do that job without being engaged in an important way and trying to develop effective coverage expansion. So we could just kind of get that on the table about the priority.
Again, the purpose of the work is to provide evidence about coverage expansions moving forward because this is not going to be static and provide evidence that they need to make better and informed decisions. That may not resonate well with some people but I am happy to spend up and use that position. Thank you for your comments on the importance of patient centeredness. And there certainly right on the mark. And I look forward to a further discussion and if you decide to go in this direction, the further lifespan of snack in trying to figure out how to make those statements real. And what does that mean for our work going forward.
I am going to go next to Victor and then return and then Harry.
In addition to the patient centeredness issue which was very strong, and the back of our minds and sometimes in the front of our tongues, we have the issue of how do we ensure that the agency's mission, whatever it is, yours now, is supported and not permanently at risk of not getting supported. One of the things that we thought perhaps is that if there are more people who love the agency because their work affects other jobs or helps achieve their goals, the sustainability of the agency could be more secure.
I think you see a long list of people that we put up there in the focus. But I think that is perhaps a simplified way of pulling out the fact that this agency affects the work of all of those people. Hoping there may be more HR queue to help them with their job. So there's a little bit of that as well that while the thing could be really focused on the promise could be delivered that is a little bit of emphasis to make sure that there is a distinct expansion for the agency.
Thank you. Victor?
Thanks. I think Elizabeth following on Victor's comment, part of the church is that we felt like we have to help shore up the agency. And having sat to the last year when we would discuss the defunding threats at what is the agency here for kind of thing. So then thinking that is all lands to think about the charge and how that part of it is lack of rain name recognition and familiarity in the community that perhaps should be the set of natural constituents and also sets of redundancy and bureaucracy whether it is the federal government or positive public agencies or time to carve out a unique place of arc. That is the head that I think that have been thinking about this.
Then Mike and Helen did a great job of distilling down a lot of hours of thoughts and conversation. They are both aspirational and functional return to get at the functional. But not lose the aspirational and lose the focus is an patient centeredness and communities and all of those things that we are putting in there. Then in the end the agency has to perform and do things. And I think that we also recognize the role that the agency has played in implementation and fairly in your articulation of the mission statement evidence that is used that really gets that a lot of the kind of things that we are thinking about and the tools that are test created and that need to be created for things to be able to happen on the ground.
Then you did talk about the work that the agency will be doing that is funded on the trust fund were actually from PCORI itself. And that is I think under the question I came up a couple of times of the conversation. So what exactly is the distinction and I think it would be helpful to our community and profession to share you describe what you think as the relative position of these two agencies in particular. Forget all the rest of them.
Well I can provide you a very quick answer. It is no accident that last year was our first outside agency presenter because I do think it is an extremely important question that I would hope that after Joe's presentation and our discussion that there may be an even better defined or sharper answer. But the kind of quick answer that we would give prior to what Joe says is in part comes out of the statute. So PCORI has provided the resources and the charge to fund research on what works and what doesn't work to fund this.
Arc has provided resources and responsibilities to invest in training and methods so that there are people who understand both how to create and the development of methods. But then even more importantly, to disseminate. And we are interpreting that or operationalizing that I should say as figuring out how to disseminate PCORI effectively. So the initiative that I described in priority what is around the PCORI work that tells us the patients and clinicians and how to improve performance on cardiovascular risk factors. But they know that it is 50% of patients with high blood pressure have it and under control. So clearly there are figuring out how to disseminate that work and that is a big gap. So sort of the simple answer is the PCORI responsibility is primarily around generating evidence about what works and what doesn't and our responsibility primarily around disseminating it work
Having said that, PCORI has got some efforts on that dissemination and on the training side we have some efforts on things that may seem a bit more like figuring out what works and what doesn't. So it's easier to say than to actually figure that out. And the tools as you identify and one is to be able to have the story that works. And explaining to folks who are responsible for figuring out about funding and such.
As importantly or perhaps more importantly is to figure out how to actually work together to get this stuff done. None of it is easy and there's plenty of work to do. On the second one I am quite confident that in the first we are still working on it.
Harry.
First but I want to thank all of our members and staff. It was a really great process and I cannot imagine what would get them in another six months but of course we will get it done. So before I just make one comment about this, I know that you know what happened during the Clinton years when arc was involved at the White House and people like that and contract for America -- [ laughter ]
Led to the zeroing out and of course it did not come to pass but I think the risks are of course exactly the same that the very same people are there. But also think that your daring and your approach to being that arm for the government is absolutely right on even despite the danger. I think if you also make it that you are an honest broker of this things that you do it you can do. Not that anyone will take it seriously that does not want to take it seriously but ultimately the goal is to improve health care costs. So I think go for it and hopefully there will not be another such contract. But the experimenting that is not that they won't do it. Says not like you want cause it. I have to say one other thing and this is a shameless plug but many of your friends from Massachusetts and here, and I did read a thing about how the affordable care act is a national experiment and the largest one done in a long time. And I do really appreciate you recognizing that and seeing this is an awesome opportunity to find out what works. Especially with a given the deplorable failure to expand Medicaid. Nonetheless, that is an opportunity.
The only thing I would add to that which I think and this is consistent is the first phrase is advancing health services research. Then the health services research and a lot of this is really something that they wouldn't get rid of and the disparities reports and all things were done internally. And then under contract they're all important so we cannot get rid of anything so this is your -- not your problem. But this is what inspires the nation and makes is the enemy of the world in terms of medical and biomedical research and ultimately the public has to understand, not just from the bedside but all the way from practice and policy. But what also happens if we leverage the tradition of the investigative initiative research.
When we go to the budget which I know that you have, this almost nothing there for new investigative initiated research. So I think that even without breaking the faith with your priorities that you nonetheless use that mechanism and that it would be something that the public understands and also engages the extra the community which is been largely alienated because of putting in applications and not getting anywhere. So I think 85% of the NHS money goes extra merely and that is I was a different than here where this is it single digit integer going back to the days of investigative initiated research and not just contracts. So that the only thing I would add is hopefully a return to those days with as little bit more than that work
So Harry, as a as of once an investigator a very much appreciate that. And then as you point out, there is some other the tension between the need for focus and the need to be able to explain to others what it is that we do and the peer investigator initiated parts, which tends not much to be focused. But I am very committed to trying to increase over time the investigator initiated work. And also I think that we have done ourselves a disservice on probably too narrowly defining what we count as investigative initiated. We put out targeted at LA's that if you ask for work in an area they can be pretty broad and there is what I consider most of the investigator initiated, even though we said that there is an area. That we are interested in. Historically we have not counted that as investigator initiated. So some of this is a definitional question.
Was that okay?
Okay will go not to Jeffrey and then to Michael.
I think this is great and I just want to comment that as I'm helping to sort of build medical homes and things like that, I am heartened at the level III status that there is a requirement that a family member or a patient beyond the quality committee, and I think that is of getting that one vetted and some of the best. This is on hospital safety committee.
What I found difficult and I think would be interesting about the transparency, is when I get down to the level of how do we make the never of events or these things transparent and then really push that. It just seems like everything plans up. So balancing the transparency and who is on the committee, it would be great to get some research about how that would not only improve safety and cost, I believe in my heart that if you can keep the patients engage to the family members engaged in safety and liability that it's better. We don't have a lot of evidence on that but that is a great start.
Michael?
I just want to follow up with a little clarification. With regard to the ACA, hopefully this is helpful. But we are thinking about overall health care system performance and struggling about how much we talk about what or how, we can go back and look at the task of the subcommittee which was the strategic direction. So there's no question in my mind or anybody's mind at the ACA is the paramount contemporary issue we have to be looking at with regard to healthcare performance but if we look strategic and futuristic that we should not have a contemporary issue frame or limit. But we will look at on the road because we don't know what will be aired five or 10 years. So it is not context that we are turned to broaden our expectation that the agency you are maybe looking at goals are priorities or specific tactics and that's why that tactic comes out and the system contact did not show up. So as we continue the next 4 to 6 month, I think that continues to be our challenge and I will be looking some feedback from you and Bruce about how much in the weeds do you really want us to get work so that will be helpful ongoing conversation.
Sherry?
So thank you to the committee and all for do tremendous work on this. And I am really impressed with how well the framework division, the priorities align without having already planned to. To do so. I do want to comment that I think aside from the affordable care act, that there is a definite shift in who the population is. Or will be over time. Son away this work can be more timeless. And to know what the population is will matter because with the care needs are and what the gaps are may also shift. So how to actually know that may be something to think about. Maybe it is a data source but also maybe it gets to goal number one which is engaging patients and families and communities. Just a thought that not all people are patients yet.
And I think that is an important point. Because one of the rising population need is going to be people with dementia and certainly goes with multiple morbidities that have been mentioned here. So how caregivers really fit into this when there really in the receiving end of official services yet, I think that is part of the solution and also part of the challenge.
I will also say that the focus on quality is very well aligned as you know with CMS efforts and the discussion of value and affordability. Part and parcel, if you don't have quality, there is a temptation for consumers to pick it is more expensive. So there is that and I'm really glad to see that these are all in the goals and separated so that it permits granularity of assessment and measurement. I think there is also opportunity to further know what works and what doesn't work. I just remember and I often sit to work that you all have done here. On why you users don't provide evidence-based guidelines because it is not there at the site of care. Is another story is because we are making a great effort at using quality and focusing on quality improve meant and the like. So there may be opportunity and I think there will be opportunity to see why improvement principles are not adopted or measures are not implemented or used in some meaningful way. So perhaps that also is a different dimension and yet it is really about meaningful use about the data and evidence of quality.
Thank you Sherry. And I would like to thank Mike and Helen and the members of this group for the very excellent work here and Mike made a suggestion or probable possibility of a six-month extension. And if you are all willing to do that, and I know that you all have really busy day jobs. But if you are willing to do that, that would be grateful. Mike asked for some guidance on direction. And for the most part, IDC our job and my job and the job of my colleagues here in figuring out how to implement the priorities and I would look to the committee primarily for the what's that we ought to be doing and that we have done an excellent and helpful job. Having said that, I would put a caveat on that and say that particularly on the first of what's on the engaging families and communities, I would be interested on your advice on how. It is very challenging area and I would look forward to that.
First of all of which is check to see if any of our NAC members on the phone or Helen who is a sub chair of the committee if they have any comments at this point?
No not at this point, thanks.
Hearing no comments or questions, let me see the following. I think it would be in order for us to entertain a motion to accept the subcommittee report and to recommend it to the director with the recommendation coming from the full NAC. And is that of that motion, to extend the life of the subcommittee for at least six months. And specifically to work on goal number one and to further elaboration of that goal is the director has asked. Is there a motion to do all of those wonderful things at once? So header you are making the motion and Harry is circuiting it took fantastic. Anymore discussion? All those in favor please say yes. All right. Thank you very much. We appreciate it. I think this has been a great interaction and appreciate all of the work that has been done by the folks on the committee that was pretty fast and furious there. We appreciate that.
Gene please.
I'm just wondering if we should expand some of the come to the membership for example working so hard on patient engagement to have a better more comprehensive discussion. And are there other constituent groups that we should be reaching out to?
That we discussed that also with Jamie and others to see whether parameters and possibilities are around that. Point well taken. Was just asking her about that right now.
So for the way the charter is written, there are the current NAC members and past NAC members. So NAC number is still maybe share your project could dissipate if they wanted to. We cannot have outside membership be part of the group just because the way it is right.
But if we look at some other past members, maybe somebody will come to mind.
Exactly and we can do that. And we can look at who was there and you can invite someone just to come to any particular meeting and talk about any particular topic.
The past membership is a big list. And it is a great list. It is actually very great list. So the company is accepted
V?
I think this did not link with the statement that which is made.
Now.
Hopefully that was not an exception. So one thing that made our job difficult was not knowing what the director wanted to do. Now we have that. So the question is whether the director wants to provide additional comment of the later stage or guidance as to what we would be most helpful for us to produce in the next six months. Because we have an agenda we said maybe patient engagement but also perhaps some additional ones because we said not only the relationship but also moderate relationships and innovations and really just a lot of things that we are calling integration and collaboration with our agencies the perhaps a little more direction would help us to be more effective.
Yes I think that is fair and I think that will evolve over time. I get the clear ask on number one as an initial point then we will see where it goes from there.
So now to give very much and appreciate it we are at a point now for public comment. So we will move into the period before you have to excuse yourself. And other we have at least one public comment signed up work so I'm going to turn to her, Lisa Simpson to speak and we may have others what as well that about aware of.. Simpson?
It's hard to imagine that the search accounts is a member of public health.
Thank you Dr. Siegal and good morning members of the national advisory Council. As Dr. Siegal said I am Dr. Lisa Simpson and I'm the present CEO of Academy health and we are the professional society for health services research and health policy. With over 5000 members. And we are deeply committed to the field of health services research and us to agency healthcare research and quality and its mission and what it does. And for many in this room, they know that the agency is near and dear to my heart personally.
Out to take this opportunity to congratulate Dr. chronic for his role and his leadership already in the first four months. And to react to the mission statement and updated priorities is vast based on work we have a doing a field of the last six months when we heard about the upcoming transition the first one in 10 years in the federal agency. These are always important watershed moments in the federal government. So we worked with our members and we received comments from nearly 400 individuals in the field and not just our research members put the users and the producers and users of evidence. So my comments today are in reaction to what we have heard this morning but really framed with the feedback from how we got from the field. But we heard repeatedly from constituents is that art plays a critical role in funding research and evidence to improve care across a continuum of activities and that the portfolio look needs to reflect the full range of those questions. So we are delighted to see this updated mission which not only continues to emphasize the safety and quality of care with the aspect of the role but not so that goes back to expand the focus of other aspect of affordability and the value of prayer. Those are all really critical questions that we heard from our constituents. Costs are a dominant issue in improving value and eliminating low value care as important. But the system performance and cost is unique and very much needed.
What I speak on behalf of the agency then we are often asked but we have PCORI now and so why do we have art for the point of duplication and redundancy. We are in a time of budget restraints so clarity and coordination of roles and I think that updated mission will make that even easier. So I commend you on that.
So I do have two additional content Thomas that were not explicitly expressed in the mission and priorities but there in there and I just want to call them out. So I want to focus on how the research is funded and infrastructure needed to make the research. That is of the grants and the portfolio that is balanced across all of the different mechanisms that we can use to achieve the mission.
The Dr. Artie commented about investigator initiated research and just as an aside I would say that the Academy health runs for the Robert Johnson foundation for changes in financing and health care financing and organization. Is somewhat narrow with organization and that is an investigator initiated research program that is highly valued and needs incredible timely results within 18 months. It can be done I agree. The second part is infrastructure. To be able to achieve this mission of the evidence for the systems and all of the partners, we need the data, the methods of the human capital workforce to do this. Is a really critical research for decision-makers in the private and public sectors and anything that can be done to release the timely enhancement of the data it will be very well received. And as you think about training, there has certainly been great evidence of PCORI Amanita be able to train the field to do this effectively but we still need to train researchers on how to do cost research and Valley research and study efficiency and ROI and all of these questions that we really need to understand. Such as call those out because they are essential.
So I just want to end of the most important point of the new mission which is the working partnership of all of the healthcare stakeholders and the importance of producing evidence that is used and understood. Because this is an impact and the impact must be used and it is very much looking forward to the Dr. and all of the members of the agency staff to achieve the mission.
Are there other individuals which would speak at this time? Hearing none, let's move now to the next phase of logistics here for our break. We are going to break now and Jamie is going to lead people to water and make you drink. She's going to lead you to lunch and then you will be asked to bring it back here. So she will be our guide on that. And then we will meet at 1140 And then we will meet at 11:40 AM in the wellness room and I think Jamie and other guidance as well will be for photographed as a group. Who really do want to do that on time so can get all of this done taking get the group photos an individual photos as well because that is important and then we will reconvene at 12:00 name. I think Dr. Michael M. Hash will be here to speak to us at that point I think we want to be on time for that and I will be incredibly timely and important. People can continue to eat at noon as well so don't feel like you have to finish by them. So we will break now and Jamie will lead us on. Thank you.
[ Event is on recess. Captioner standing by. ] I am very pleased that he is now here at AHRQ and I know that he will continue to make important contributions to the work that we are doing at HHS and across the administration. So it is a pleasure to be here and to be with right.
I thought I would try to do three things in the time here and then leave the sufficient amount of time for questions you may have. First I wanted to talk about where we are in implementation and more particularly the healthcare.gov website and the issues that have confronted it and where we are and where we are going.
Secondly, I would like to talk little bit about the first enrollment report across the country in the new marketplaces which was released this past week. And then talk to a little bit about the announcement that the president made yesterday morning around noon with regard to cancellation of individual artist and group policies and what options were being announced with regards to the policy he talked about.
Let me start by saying whatever dirt about implementing the affordable care act you won't be surprised that we always have to keep our eye on the big picture here. So the contribution that the affordable care act as argument to millions of Americans including things like allowing dependent children or adult children, adult children to be on their parents health insurance policy and the opportunity to access free or no cost sharing preventative services. And the opportunity to be protected from arbitrary revisions and policies. And a series of other protections that are are ready and place. The discipline that we began to impose on the individual and small group market through setting a standard for their expenditures relative to that but instead of overhead. And some of you may know it as the 8020 rule which is to say $.80 of every premium dollar should be for covered services. And no more than $0.20 of that dollar go to other activities including overhead executives etc.
That standard has produced a very significant benefits for consumers in the form of cash rebates and so forth. And I think has obviously made some contribution to the significant moderation in premium increases that we have experienced over the last several years.
So again I think it is important to realize that the affordable care act is much more than just a website. It is really about bringing access to affordable quality health care to all Americans.
Let me turn to a minute to the website and where we are with respect to healthcare.gov. About 2 1/2 weeks ago are close to three weeks ago now, in the wake of the disappointing performance of the website beginning in October, the administrative and particularly it is just take some aggressive steps to address the problems and to remedy them as soon as possible. Steps such as that we actually brought in a much enhanced team of experts in software engineering and other expertise that is relevant to the maintenance of the website as complex as healthcare.gov. The tech team included individuals who are employees of existing contractors for supporting the website. But it also involved bringing in some other technical experts and individuals who have been individuals together with respect to IT issues and the like and those individuals are really bolster the resources that we have to attack the problems that we face.
Secondly we took one of our existing contractors and QSI which is affirmed that you may know about that among other things has a well-known expertise in the management and those kinds of things with respect to a large project and large complex project. And we installed them as a project manager with respect to IT contractors.
Lastly, we actually talked with a call Lake who was at the time a former colleague, Jeff resides, we may know at one time he was in the Obama administration and the acting director of the Office of Management and Budget. Prior to that was the principal deputy for management and it is private-sector career is a well-known and successful management consultant. But now for the practicing counsel for Maryland Tavern is the administrator of CBS. So the integrated team and coordinated approach for changing the problems of the website has really named the problems anybody way. So one thing was to identify where the problem were ever the fixes would be and when they could put into play and in effect going through punchless that allows us to in effect prioritize the things that were most important to improve the consumer experience with respect to healthcare.gov. For example in the very beginning, the major problems of the website were experiencing with the very front end of the process. This is the place in which individuals established an account and further going to be verified as to who they are through process that we call identity verification. The front and peace office was not working appropriately and people were getting hung up there. That was a big priority and that has been largely fit. But with few if any delays with respect to the aspect of the process. Next step not surprisingly was various things that started showing up as the volume increased on the application process which is the next step after you set up an account to get verified. And there were various problems in the application software and in the functionality. And the pieces supporting the application process, that became a very high priority and I think we have moved through and particularly we have talked about pretty much daily, metrics that show that we have accelerated the response time of the website, how we have improved and eliminated many of the software glitches that were preventing a smooth operation of the application process. And lastly we have been prioritizing changes and improvements to the way in which the website relates to insurance issuers and to agents and brokers, enabling them to in fact to direct enrollment into the system. Obviously those are stakeholders in the process in enrolling people whenever they can. So we have been fixing that part of it because it was not working appropriately. Secondly there is a backend piece on the website that actually communicates from the marketplace to the issuer of choice of the individual. Sending them information about who has pick their plan and how many people in the family and other important contact information and demographic information, to enable the issuer to of course affect to it enrollment in the choice that the individual has made it that is a process which we have been fixing and completing and we are now beginning testing with issuers and others to make sure that in fact that process is working smoothly as it was intended to do.
In addition while we were having the website of problems we were of course trying to make sure that the other channels that were available for other portals for individuals to apply for and get an select a plan of their choosing, other portals exuded the 20 47 Call Ctr. in which was stopped staffed by individuals who were and are able to take people to the application process and take them to the plan compare or the shopping center if you will of the website so that they can evaluate what is available to them and what meets their needs. And then ultimately, enable them to select a plan.
We also as you know I have invested in a large number of people around the country in the form of either navigators were trained individuals working with and for organizations that we granted money to around the country. Many of them community-based organizations to opposite have a network of connections to reach out and identify people looking for coverage and help them find it in the system in that process. They would have an even larger number of people associated or affiliated with organizations that actually trained of them to become certified application counselors.
And then beyond that, we have a large number of private sector advocacy organizations were also helping people such as organizations such as hospitals, not surprisingly, and other community-based providers around the country. We want to make sure that all of those avenues, that is to say of it is on the website on the call center and in person assistance are fully available to people as they try to seek and avail of coverage that would be available to them.
I should say, that we are also at a point where we are on track and confident that by the end of this month, we believe that the healthcare.gov website will actually be operating smoothly to the vast majority of users who come onto the site work that is obvious a critically important. Because as you know, for people who either don't have insurance now or whose insurance is terminating at the end of the calendar year, then order to make sure they have coverage effective on January 13 they need to build the sign up and pick a plan by the 15th of then order to make sure they have coverage effective on January 13 they need to build the sign up and pick a plan by 15 December. Oversee the enrollment period continues this particular initial year all the way through March 31 of this year. Buffer people again you are in urgent need of coverage, then need to sign up above 15 December. With like we are prepared and one of the things that obviously we're doing in addition to all of the site work that I just referred to, it is building capacity to make sure that the use the plumbing analogy to make sure that the pipes are sufficiently large in diameter so that you go and other entities that are helping people can get through and help the process and get a determination.
That may prevent for a moment to the enrollment information that we released just this week. I think the first thing I would say is it is pretty clear that the problems with the website had a depressing effect on the volume of people who actually proceeded all the way to select a plan. If you have had a chance to read the report, either the report was put out by the office of pending an evaluation that HHS. But many press reports of course have followed up on highlights.
But what I want to say is I think it but he respects the reports missed what I would consider the more salient and see if he can findings in that data. That is to say, we had in excess of 1 million people who in fact have come onto healthcare.gov, completed an application, and had a determination made about either their eligibility for private insurance plan, and for many also financial assistance in the form of a tax credit pick and others who a eligible are assessed for eligibility in the Medicaid program
So to say that the website is not working is clearly not an accurate portrayal. It is working, it has always worked. Not to the level of performance that we would like, but each and every day and each week, the performance has been improved. And part of the metrics or one of the metrics that underscores the functionality of the website is that over 1 million folks who have gotten that far in the process.
Now you say why have more of them not chosen a plan? I think there are likely to be a variety of reasons. The experience of places like Massachusetts for example, when they rolled out their website, it was that in fact on average I think he was 16 or 17 or 18 times the people came back to the website to reevaluate what was available for them. So the decision is not sort of a continuous linear process. By the time people get to the end and find out what is available to them and how much it will cost them, they also obviously want to talk it over with trusted sources and their family to make a serious decision about what works best for them and all of this. So I don't think that we should be particularly alarmed that there is a Delta between the people who pick the plan and the people who are in a position to pick a plan. And we expect that difference to close and particularly close more rapidly as we get into December.
So in terms of the actual total enrollment countrywide, including the state of the federal marketplaces, roughly 106,000 enrollees and people will pick the plan. And of the group, about 70 or -- let me make sure give you the right number -- 79 or almost 80,000 of those people who pick the plan were in fact doing so on a state-based marketplace. And the rest of those individuals in the 106 total were about 27,000 people actually picked a plan on the federally facilitated marketplace.
But again, as I said, the number of people who have gone through the application process and had a determination made and are poised to make a coverage choice is quite encouraging for us. So I think that is the story that I wanted to tell you about the enrollment picture. Again, once again, we fully expect a significant increase in volume beginning at the beginning of the next month. So the people who want to can be assured that they have coverage by the first of the new year.
The last thing I said I wanted to talk about briefly was the announcement that the president made yesterday morning. This had to do of course with the status of nonqualifying individual and small group plans. And the prospect of the determinations that have already been issued by the insurance company sponsoring those plans. And of course the fact that these notices would likely continue because there is a kind of rolling plan and policy characteristic to how people get to the end of their coverage period. And so, at least the insurers tell is that of the plans that would likely be terminating or canceling, about 55% of them have Artie sent notices. Which of course means another 45% are yet to come. And typically one would expect those to occur, mainly during for individual plans it maybe every month. Because people who sign up for an individual plan or set up for contract for a year, and whatever year they sign up, their anniversary is a year later. So those are rolling basis. At first more groups, typically the big bump start calendar year and quarters like it but one or July 1 or October 1. That is typically when employers have renewals of the group plans. So that's why this issue is coming up needless to say because lots of folks were getting these notices. And I think you have read enough about this to know that some of the issuers who put out the notices were -- in the vernacular then you have to message this in a very effective way by telling the enrollees and participants that we are changing in terminating. But here's another plan that we are offering that is compliant and 2014.
However, you also will have other choices if you're interested. You can go to the marketplace in the state and in a place you can find out whether you might actually be able to get financial assistance for a plan. So that in effect, instead of saying that you are out of luck, it was a much different message. Then others were not as sensitive and then the plans terminated. So I think that was a source of confusion and alarm for those people receiving them and I think the president in particular was concerned that people found themselves in the circumstances and further, that they had relied upon an understanding of this piece that is quite well known that if you like your healthcare plan that you can keep it work I think you wanted to address that and take responsibility for the disruption that some of these people were experiencing.
So what he announced yesterday was in fact that exercising his executive discretion to postpone the application of some of the market reforms in 2014. And a loud noncompliant plans to continue into 14 those that are expiring into 14 to renew up until September 30 of 2014.
The conditions for renewal of these noncompliant plans are first that the plan must have been effective for an individual, at least by 1 October of 2013. And then secondarily, for an issue or who elect to continue these types of policies, that they have a notice requirement and a pretty robust when requiring them to inform their policyholders that the plan will be continued but that you should know that it will not into the protections that are otherwise available from individual and small group market plans and the marketplace. Things such as gender rating prohibitions, annual limits, age rating limitations. And of course most importantly in many respects, demand that existing condition conclusions. So those features we would have to say are not part of the plan we are offering you, but other plans that are in the marketplace and in the markets that do in fact meet these protections. And as a result, if you want to go there you can. Or you can stay in this policy.
The other feature of this, besides notice, is that we recognized that is doing so, probably the folks who are holding individual market insurance today, who have been -- if you will pardon the expression -- massively underwritten in terms of their status. Whether there are 25 or 55, their above average in health status. By definition they would not be holding such a policy.
So I'm concerned and it is certainly grounded in the fact that depending on the size of that cohort of people who elect to do this, it could otherwise affect the characteristics or the picture of the risk pool that is in the marketplace and 2014.
Clearly since the premiums for all of issuers participating in the market and 14 are baked or are already fixed it will not be changing, it could affect their performance during the 14 and then subsequently be reflected in premiums that they might bid for 2015 calendar year.
As a result of that, then we have some premium stabilization tools it affordable care act. One of which we have highlighted in yesterday's announcement which is something called the risk Carter program. Which is pretty up much a policy that protects to some degree losses from mispricing that the insurers may incur. That is to say the premiums compared to the claims experience are significantly above a target they could be somewhat protected from that loss. The way it works is the first 3% of your loss is the issuers problem. From 3% to 8% is a 50-50 split between the federal government and the issuers so the government takes on 50% of the loss above 3% then if that happens to be above 8% in the federal government takes that 80% of the loss and 20% being the issuers. So it was a tool designed affordable care act to mitigate premium mispricing in the marketplace and to obviously offers some attraction to the insurers. Particularly when you consider that fully a quarter of the people entering the market this year and next year are issuers who are not in the individual market before. This is brand-new for them.
The other tools such as the individual market plans that all relate to in effect trying to modulate the risk that the plants may incur and encourage them. Because they have greater protection and production in risk because of these tools.
So we talked about that. Then for the continuation of these policies, then the most important piece of all of this is the size of the enrollment on individual it's more group work at risk pool if we are successful along with the states it really getting a robust response and getting a large number of folks into the new individual and small group market, that compares to the relatively few numbers of people compared to that who may be in the continuation policies that may have a huge mitigating effect on premiums that as a result of the changes the complexion of the view of the risk pool going forward. The other thing I would say is the mitigation tools that I mentioned is could also be a contribution to that. So we actually fill that it is not the next year and 15 that they would never be a premium increase, even though we have the lowest rate of healthcare cost increase in premium increase in decades, the truth is that we expect that truly there is some increase in healthcare costs every year. I think the trend is running about 5% or 6% of somewhere in the neighborhood. That what we are talking about the other number is to have to start on top of those risk premiums because of the change of the risk pool. So that is essentially what happened yesterday.
Again, I think that we are very confident moving forward that the website is going to be fixed. That we are going to attract a very large number of Americans who have been seeking for a long time to have their coverage and have been often locked out price& Of the coverage that they have had or could never get work and so all of the indicators at all of the metrics then we have had over 30 million unique visitors to the healthcare.gov site since October 1. Not that everybody's there to buy insurance but there's certainly a lot of interest in all of that. So I thank you for the chance to come and talk to about this and I'm happy to take what questions you may have.
We will now open it up to questions. [ Captioners transitioning. ]some of it with purpose and motivation but some of it not the products on the shelf at least relative to what's available in the individual market today are in most states quite attractive peirk first there is a pretty robust participation and there are some states and trouble but most places in the country pretty good participation as Mike mentioned ,-comma a quarter of the issuers offering products have not been in the individual market before peirk some of them are plants that use the be Medicaid plans that are coming into this market peirk the premiums have on average been more favorable certainly in the Congressional budget office expected and more favorable than many people I-pronoun would say myself included expected and so the products on the shelf ,-comma -- products on the shelf ,-comma healthcare and United States is very expensive ,-comma it's still a lot of money for a product that typically has $2000 or so deductible even higher than that and Brown so it's a difficult product to sell but it is a more attractive one than many people thought we would have and 2014 peirk clearly but that difficulty getting people to those products Mike is talked about the problems with healthcare .gov but the other big concern that I-pronoun have and some other people as well is what -- what people know about thishis peirk will there be interest to ask -- will there be interest quex and I-pronoun was concerned that we have these products out there in the marketplace would open and there will be much information about it and the several lining to the troubles as I-pronoun am not so concerned about that anymore and is Mike talked about there is quite a lot of interest and fingers crossed at the end of the month as on my said healthcare .gov is able to process the vast majority of folks going throughgh I think we will be in good shape and for many of us who are involved day-to-day with reading the papers and working on this and a difficult environment but it's been commented by many people that we are likely to look back a few years from now and say a little bump in the road peirk with that, let me open questions for Mike peirkirk.
Good afternoon peirk thank you for coming I know you must be incredibly busy and we really appreciate the time that you take to be with us we spent a morning talking about mission and priorities for AHRQ going forward so I would like to hear what the areas that AHRQ might be able to look at some of the uncertainties with a CA implementation.
Sure I want to give the disclaimer here that I am not a health services researcher or anything like that, I'm just a country lawyer.
[ indiscernible ].
I will learn from Rick. What I would say it's a did not even talk about another I would talk about the twinkle of the affordable care act which is the history -- about that when goal of Affordable Care Act. I think AHRQ is well-positioned and not just now but in the past to make a contribution to help analyze what kind of approaches work, what kind of delivery systems actually move us away from a volume -based system to a value -based system that help us to have better metrics about outcomes and quality and have really the rewards in the system go to the deliverers of times times delivers of healthcare services will really have high quality and efficient delivery of services and that's where we have to be. I would say under times I think everybody working on this with a if we are not successful in improving on those lines of improvement then all of the insurance coverage in the world will not be sustainable because of affordability. I think in shorthand there is a lot of different aspects of times of what we're trying of what we are tran2 June times times trying to do and delivery system reform which is for the first time really. And extraordinarily large R&D budget for delivery system reform and I think it means as we roll out the various pilots and experiments that we are working on they need to be informed by the kind of work that goes on here to make sure that we really have the best start and then of course the key evaluating what we're doing and drawing important lessons from those experiences so that we can quickly scale up the things that work and not pursue ones that are not proving out.
I would just add that what a presented this morning in support of the secretary and I hope we will be and I think it's important that would be engaged in trying to [ indiscernible ].
I should've said that. It's the age-old, not so atopic the question about what difference does insurance make and embedded in all of that is different kinds of coverage and what kind of outcomes result from it is a times the key evaluation job that needs to be undertaken.
Thank you very much. You know we've had this access battle, we have the payment reform battle and I have for years been think access to what quex and I look forward to the time when we will provide the access and then we can begin to talk about experience, medicine, the right kind of medicine at the right time but insurers have traditionally paid for many things that weren't worth it. So I don't know how we move that discussion to the best kind of care at the right time. I think CMS is beginning to do a really good job but the rest of the public isn't getting what CMS is getting.
My own view of this is how this sort of becomes more acceptable that is to say improve delivery system model comes more acceptable and has -- as more and more people experience benefits as being in something like an accountable care organization or medical home or whatever it might be and they will want to have that as their delivery systems for themselves and then of course stress the negotiations that bond between providers and insurers and also forms insurers about how to design their benefit packages and coverage decisions and so f orth. I do think you have to in terms of public acceptance you have to show people how it works and they actually can experience the benefits of this change. I am sure I don't have to tell anybody here, change is a very challenging undertaking and no less so in delivery system and implementing the Affordable Care Act for access improvement. I don't diminish the challenge that lies ahead but I think far from the next but when it look around and meeting here and talk to people who are much more involved in this than I am I think there is a real enthusiasm for moving in this direction maybe it's not so fully in place and the public but clearly in the provider world as I have gone around a little bit and listen to provider organizations, people want to make a change and want help in doing so I think that's very different at least right now. I'm optimistic we are going to have success and as we do a think the acceptability and the effects on insurers and the effects on public will accelerate this important change we need to make in the way healthcare is delivered in this country.
Mike, first thank you for what you doing. Anything that has this much impact is not easy in your kind of leadership is what will probably get us there. There are two things of things that we have already done and it's where we came from and what Waretown to solve. To that, Medicaid expansion some of the hybrids. I'm a space right now that is waiting for waiver to be approved at times something like Arkansas was approved that has this part under 100%, it's Medicaid that's not ORIs commercial can you speak a little bit to how you think that thought fitting together and where you think that peace is going quex.
Obviously the original intent was that all states would affect -- would in fact extend the programs to 100% of the people on the poverty level. In the wake of the supreme court decision that became an option for the states. At least in the political world that we find ourselves there have times had been a number of decisions made not to do this and I think those have been misguided is what I would say but nonetheless I am encouraged by not fast enough but the evolution that we have seen of political leadership in the streets that have not been moving more quickly in that direction. Ohio is one. Certainly Arkansas was at the forefront of this and I think that our belief is that over time all of the states will come to this. Apart from the important financial incentives associated with doing this and apart from the value providing coverage for many low-income adults in the country, the other thing here that I think is really important is that people -- I think people appreciate that there's a whole group of people for home healthcare access is not available and therefore inhibits in so many ways the economy and a lot of other things that they will ultimately make a judgment that this really is not only the right thing to do but it is good politics, good economics, and I am very optimistic. One reason Rick taught me is if you look at other programs that were optional in the most recent one in particular was the chip program, when it passed in 1997 there were a number of sites that that were not doing this. Within three years every state have a chip program. I'm Polish on the prospects that this will be coming. Not soon enough for the people who are left out but nonetheless I think we are going to get there.
A minor comment on semantics. You might describe the program as optional it's still mandatory but just mandatory but not any sanctions if the state doesn't do it.
He's read the decision of the Supreme Court very closely.
[ Laughter ].
Just wanted to thank you for your service. This must be one of the most difficulty periods in the times the work that anybody has to do public service if we don't spend enough time thinking people in public service for what they do. You and your team I expect are doing incredible work and we just don't think -- we just don't think you enough.
I appreciate that. Thank you very much.
Just a follow-up on Andrea's Medicaid question. The last time I saw you were fighting about dish.
We might do that again.
[ Laughter ].
I do hope is you and AHRQ work together that you also look at some of the new Medicaid models that you may wind up having were signing off on Arkansas premium support models and no point of view whether they're good or times or bad by expect you will see more of them and hopefully expand just to get into taking place and some of the southern states.
I agree and I think that is the way most states are thinking. As Rick knows again the only way I can remember the statistic accurately that the vast majority of people in Medicaid today are in private managed care plans. 70% or something like that. Not surprising that as states evaluate further expansion they are thinking if they are satisfied or they think that's approach to delivering services to this population is working for them, they would want to do that and as Rick mentioned a while ago a number of new entrants into the marketplace offering individual coverage in insurance are in fact companies that have huge are forbidden exclusively Medicaid managed care companies. There offering our products the wider population and I think there's a case to be made and those kinds of circumstances that networks and other attributes of managed care would actually enhance the access of people in those plans above may be what had experienced in the past. That's I think we are going to see clearly the Arkansas premium support approach for folks above 100% of poverty is one that is actually attractive to a number of other states.
As I think many people know, as Mike said much of Medicaid particularly for low-income women and their children, a little less so for people in the disability is a managed care, and Arkansas is one of the few states that didn't have Medicaid managed care and so for them as their looking in expansion it kind of makes more sense to say we don't have managed care times care what are we going to do. A state like Iowa were think you had some managed care but not too much.
We have great managed care one my company does that.
[ Laughter ].
That's a different story. And certainly as we try to understand one of our priority should be understanding the effects of expansion and I would include in that this question of trying to understand different ways of delivering services to Medicaid beneficiaries want to make one comment before I got here the agency has been involved in the Arkansas piece in the following way that Tom Selden who works with Steve Collins in the center for financing and access and cost trends have been at the request of the Arkansas Medicaid times Medicaid program and did some work on developing a model to try to figure out dash Arkansas is trying to figure out how to keep 10% of the most [ indiscernible ] folks out of the marketplace plans they're trying to figure out how to do that and one can debate whether that's a good idea but they ask for help in turn to figure out how to do that and Tom worked with the maps data to provide them and algorithm to it beats -- at least get started on that. Still some issues and troubles with that but we've had some involvement there.
And just to what you said we talked about this being a laboratory, there are many different managed. managed care companies and Medicaid with a lot of different ways of measuring what they do in many different states have this measurement or whatever times times or whatever it is and it seems to me there's a whole times whole laboratory that's been percolating up there and now we have controls with people who don't have Medicaid expansion. It seems to me that the natural made laboratory we should make use of. I know the managed care companies talk to each other all the time and they would be very good at giving their data.
I also wanted to thank you very, very much for coming it's really a pleasure to have you here and thank you -- thanks for making time. I can't imagine what your days of like. I just wanted to offer another recent example of a Medicare expansion plan that was of -- that was successful. I'm affiliated with the national breast Cancer coalition we work very hard to pass one in Congress and of course we had to go to all 50 states and that is a program that is been implemented in all 50 states. Very quickly within two years, and think two and a half years it was implemented with the enhanced match of 60% as opposed to 95% are 100 and for three years but along those lines one of the things we're concerned with as well is that women who qualify -- the Affordable Care Act and other dash we are very pleased to support the Affordable Care Act am pleased to have about -- been involved in advocating for its passage that there are some concerns about women who may have qualified for treatment under the expanded access of Medicaid access of breast and cervical cancer treatment that they also not lose their benefit in this way so we are continuing to monitor that but I just wanted to offer that other example of Medicaid expansion times expansion that was the -- successful. Spak -- thank you again for coming in. I represent and work in the home health industry and the organization I work work at this point in time we have 10,000 patients we're taking care of so my question comes a little bit from a broader if the patient and family perspective but I want to ask a little broader perspective when I listen to the conversations about the Affordable Care Act one of the things we talked for clinicians about is we've got to change behavior. We are in the most aggressive behaviors change experiment at least in my lifetime the we talk about value and sort of the simple value calculation outcomes over cost. A lot of the conversations that I hear really boils down to that but we are finding if it doesn't resonate with the provider and it doesn't resonate with the patient but what we're seeing is we are tying that to the mission and vision of the organization so tying the purpose. What is a clinician get up every morning get out of bed and go take care of people? Why does a patient get up every morning and get out of bed when it's painful. How do you see the administration and the present -- President be more explicit about the purpose and the emotions of why we're doing this. You started your talk about reminding us about all the good that we've done in you had to remind remind us goes it's not front and center. I think there's an opportunity to work -- to look at value in the multiplier of purpose and figuring out how to [ indiscernible ] that can resonate and stay connected with this over the long haul and in the hall. I appreciate the work that you are doing and I'm interested in your thoughts the how we can infuse that.
Again, I think you're onto a very critical point which is this kind of constant reminder to the public about what we are trying to do and why and what's good about it for them. I couldn't agree with you more the decades has not been fully made under think that's what you're saying but at the risk of sounding like it's an excuse, in the current environment there hasn't been a lot of time to talk about that but I'm hoping once we get past where we are now that much of the conversation from the public sector will be that way in partnership with provider organizations because obviously we can't do that either by ourselves and making that case is really important. The other thing I would say is as I alluded -- as I alluded to before I think there is a difference between providers impact the shutters depending on where they are in their careers. And I think that's true of all of us, myself included so what is very encouraging to me is meeting with a lot of younger practitioners who believe this and are committed to help make this case and are fully supportive really of change whereas I think the gradient is over that age cohort is that there is a little less enthusiasm the closer that one is approaching the conclusion of their career that's probably true everywhere but I am encouraged because time goes quickly and these people who gotten the message in the provider community I think are to be the leaders and that community and that will be extraordinarily helpful.
I think the opportunity to harness the enthusiasm of the earlier.there's is the way to sort of slingshot this.
One of the things we did in the early pilots on new delivery models was to organize and work with the group of delivery systems around the country that we label as pioneers because of the thing and the point you just made which they are on the cutting edge of successfully making the case and actually delivering it every day and we thought if we could work with them and learn from them it would help us to scale up similar activities across the country because those pioneer accountable care organizations have been achieving really significant results. That's what I would tell you.
I'm sure this is a more pleasant environment but if you have time for one last question?
If they do. Just real quick, thank you for your public service. I wish Congress would say that were offered to you.
I would like to know what you see in the next 10 years. I've been through the HMOs, the 90s was managed care, I've seen Medicaid states go from fee-for-service the back again, we've gone from PPOs the EPO's the HMOs and now we are a CEO's, which have never been proven to be effective yet but where do you see the market shaking out as? It's a tough question and I'm sure you will be politically astute in answering it.
I don't know that I really have the crystal ball of 10 years from now what is going to look like. I think obviously I don't actually think it's going to look like the organization and structure we have today. I think getting near is going to be challenging and they also don't think there is a silver bullet. My view is that we have to find a variety of ways that actually achieve the goals of value and quality as well as affordability so that it's not just ACO's, they may work in certain communities and many providers come to me and say I'm in rural Iowa and E what are you talking about? I get that and that's what makes this challenging because we have a heterogeneous set of circumstances around the country but I do think we are on the cusp of significant change and I don't think anyone disputes that the system we have now that's been generating not so much recently it had been generating really unsustainable cost increases is just, we can't afford to do it. I'm not sure what the ultimate outcome will be but clearly the resource question will drive what happens in terms of how we figure out how to deliver high-quality affordable care. I don't have a picture of what is going to look like.
I am confident that we will have [ indiscernible ] in our future.
Other weird arrangements.
[ Applause ]
We will take a two minute break until we come back.
The first Executive Director in the only executive director D r. Cory. You for coming to [ indiscernible ] Joe was the director of the division of research at Kaiser Permanente in northern California. He had a really high stellar group of investigators and did wonderful health services research and in his own right while there and work in the area primary care delivery, diabetes, quality improvement, very accomplished surgeon and Corey in the country was fortunate to recruit him as an executive director as you know I'm in the position on the board and already raised this morning is a question of what is the relationship between [ indiscernible ] and what should that relationship by Angela Knight along with [ indiscernible ] and others here and jewels staff at [ indiscernible ] as well as board members had quite a few conversations about that already. As -- we're not the final answer to that yet but we're working on it and we are delighted Joe has been able to join us today to help frame that discussion as we move forward. So thank you. Thank you, loss. Brick by my calculation Rick has .047 share them by my boss is only 21 members of the board of governors. I am at least is delighted to be here is Rick is to have here and while it perhaps have happened earlier, this is really a very good time for the business. We have a clear sense of who we are now and are probably better to engage in a really meaningful discussion. I suspect that you have thought about the relationship of the advisory Council to AHRQ before. We should think about it a lot at PCOR I get asked how do you relate to AHRQ. What is the difference between you and AHRQ Kirk if this -- there is a rationale for being able to speak and think and act clearly and that regard because we do need to be demonstrate that we are complementary to each other. I think it's in our interest and we certainly want and wish to more -- Dumont collaboration. For those of you who don't know much about PCORI yet, I think it's going to be important for me to just say that the few directions that we've taken in the few ways that we think and then they just want to say a few words about decision-support and CER it's a new topic to us and something that's hitting her squarely in the face we are addressing it basic it also speaks to the AHRQ PCORI relationship and do want to talk about building research infrastructure because that's an interest that AHRQ has put a lot of work into and just a few slides on initial thoughts on the AHRQ/PCORI relationship and we are doing it with brick and 18 and others in your VA interested in advancing that -- and others and we are very interested in advancing that. It's post a help all decisions and stakeholders make high-quality efficient.
Conducting research [ indiscernible ] and that. Purpose research [ indiscernible ] and findings. Our board took this purpose and converted it into a mission statement that we help people make informed healthcare decisions and we help them improve delivery and outcomes and they added these words at the end which really do I think plaintiff the sum a distinctive direction though I hasten to add again as in many things AHRQ was a forerunner and issues foundation and contributor but they said that it comes from research that comes from patients and caregivers. The notion was there that effect you really have to engage with the and uses of the research if you want your research to make a difference. So we do. We bring large number of patients and other stakeholders to the process of topic generate -- we have advisory panels that prioritize, we have a large engagement staff that reaches out to all stakeholder groups and individuals and particularly organizations to get the topics that need to be researched. We involve patients and other stakeholders on her merit review and are peer review the study sections activities to extend never before seen never even at AHRQ and we require that researchers include stakeholders and patients and other stakeholders on their research team and ask coinvestigators with the researchers so that's novel that has been of shaken up research community a bit we continue working with him on defining what it engagement means end on evaluating whether this level of engagement makes a difference. We do all this in large part because we think that having these and users involved in the research and reviewing the research and conducting the research know that it will be there when it makes sense to disseminate research there will be a better chance that the research will it implemented. That's why we do it and we also through our advisory panels [ indiscernible ] an ongoing way of looking at our portfolio and making suggestions and what comes next. We have identified our strategic plan and three goals in all of our activities latest towards one, two, or all three of these goals. The first post Justin stated SHIRLEY increase the quantity quality and timeliness of useful trustworthy evidence available to support health decisions. So key words here include want to take so we do have a lot of research funding to get out the door and the next several years, well he does speaks among other things are methodology committee which is you know appointed by the GAL as well antiworker the closely an increasingly to improve the quality of our research and in the word useful. We are very interested in understanding and defining engaging our research by weather turns out to be useful. The second goal is displayed -- speed the most -- implementation and use of the research effort he talked about how engagement these two improved chances of implementation but we are also charged with disseminating it will end this is a place where we need to negotiate for manage because you know legislation depends on AHRQ to play big hole in the third is to [ indiscernible ] to be more patient centered. We got the name patient centered, we've really taken it to heart, we believe we have some novel approaches to research right answer a variety of mechanisms we want influence of others to research. One of them is school funding process -- projects with things like arc and NAH insisting that the principles that we've established for doing this research are applied with our money in collaboration with these agencies which sometimes have more skill than we do it actually managing certain types of research. Those are the three goals and I said all the verticals drive to one or two or three of these goals. We had to we had to set up national priorities and we did, we didn't say we wanted to do diabetes heart disease mental health and substance abuse we said we wanted him five party RJs -- pride -- wide Rod areas. Improving health systems and if you don't improve health systems [ indiscernible ] how to communicate and how to disseminate research and the for this addressing disparities and we think it really has a close link to identifying and ultimately eliminating disparities in the fifth is about building infrastructure. Methods infrastructure and data infrastructure were doing comparative effective research more of it and more efficiently and more affordably and actually more based in real world settings for the findings are like Lee to really change practice. Those are the ways we spend money. If you want research money and has to be one of these. You might recognize is a bit of overlap between these and people do some the same proposal to one, two, or three a particularly strong is an amazing connection improving healthcare systems and addressing disparities.
We have to funding mechanisms at the moment. One of them is brought solicitations, this one solicitation for each of those priorities I just showed you we just saved us your best ideas, there must be questions that matter to patients and outcomes that matter to patients and they must be done in populations that matter to patients. And when we receive the applications patient's Poss -- partner with stakeholders and we get a very diverse profile of high-priority questions but we review we review on five criteria and their distinct from view sections and either NAH or arc applied -- AHRQ applied first is called the impact or burden on health individuals and populations in the 2nd and it's difficult to apply but we work hard if the potential for this study actually change practice and improve care and outcomes. Of third is technical merit and that includes reference and search protocol the 15th and the environment and patient centeredness in the fifth is patient in stakeholder engagement. That is the fate applications. That is distinctive and it's caused a lot of discussion and the research community and we continue to work on that with the review panels.
This is the yield so far. 147 studies I believe it's on the order of $220 million. And you can see it's difficult to see but the point is that because we did not specify particular conditions, we really do have projects funded and everything from end-of-life care and chronic pain the sexual and reproductive health and infectious disease and cardiovascular disease mental health include cancers and read their so there is our portfolio really does not [ indiscernible ] Ginny particular condition.
We have a second path which is called the targeted pathway and this is where PCORI sits down with stakeholders and identifies high-priority questions in advance and issues targeted funding announcements in concert with our board and with our advisory panels on selected topics and we want projects that respond to this question. This is a little bit later. Now underway. In this process we step to getting ideas from a wide range of sources shown on the left there under topic organization. We work with AHRQ we have a contract if we work with others to do the kind of preliminary work to assess whether these questions really do represent research gaps. We represent topic breaks -- briefs and we come up with a list of high-priority topics that go to the board of governors we choose the topics that we're going to do targeted funding announcements on. Of the right you will see the top three and actually I think applications have already closed for both the safety and benefits of treatment options for severe asthma and fall prevention and the e lderly. The first one is interesting because this is a treatment not meant -- treatment options for uterine fibers and women who wish to preserve the ability to conceive. This project is done in collaboration with AHRQ. -MOU with arc ending will leave the reason you of the search they will abide by our conventions for how that review gets done in terms of the composition of the study section. We will have project officers from PCORI working with project officers from arc and that was idly by committed $20 million and we are building the registry building arcs and conducting [ indiscernible ]. I think that one is still open for not sticking, is that right, gene? Letters of intent are due today. Good. The second one is asthma we are manageable -- managing that self and we just had the reviews of those in the third is a single large study and single large multi-[ indiscernible ] study on the elderly in this is a randomized multicenter trial, $30 million for one study. The fourth, back pain the fifth [ indiscernible ] I will add and primary care and support committee is now I believe approved for moving forward to prevention and management of obesity and we will have a number of targeted funding announcements amino this year. They now come from our advisory panels. I wanted -- that's it on PCORI. I wanted to say a little bit about decision-support. We have looked at the first three cycles of funding and if you subtract out the methods of of funding it gives us 126 projects and I will say in this audience a little bit to our surprise and an amazing proportion of these 29% overall and 40% of the projects but we call the clinical effectiveness are the assessment or prevention of diagnosis and treatment options priority area. 40% of them are not about head-to-head comparisons of two options. They are about helping patients make decisions about selecting an option. Only one in the disparity falls in this category. We expect a lot of this in the communication dissemination and indeed 55% of the projects and that perjury -- priority and altogether 30% of her projects we are funding it PCORI about decision-support this is what many of them look they start with it evidence synthesis kind of an ad hoc evidence synthesis, patients clinicians and researchers than the tub together and devise some intervention to support decision-making usually some kind of a tool and then the tools are evaluated in comparative effectiveness studies so it's comparative fit effectiveness yes but of decision-support tools there are two views of the situation that faces patients today. The first is we don't have enough information on the shelf. There are a large -- there are large gaps of knowledge, poor quality and evidence and we need better research. The other view is that the shells are relatively full and the problems are that information is not consistent that -- synthesized in presented in ways that are useful at the point of decision-making. There really are not many effective tools and those that exist are not in use the shared decision-making supported by good decisions the support tools is not happening. And when I kind of take this choice the research communities particularly or other stakeholders is a very mixed reaction and everybody agrees that both are important the relative mix of what PCORI should be funding is up here -- up in the year. It just puts us on the table because I know this decision-support leads into dissemination. AHRQ is on the legislation we will also be discussing this with the board this coming Monday. I now want to talk about about research infrastructure. The slide is just Mike a mosh to all of the DC based and to these spend money trying to build a national research infrastructure and AHRQ is well represented and work contributions are a lot on [ indiscernible ] practice-based research networks, registry and some of the later second generation ideas spanned prospected idiom format and really taking this work forward and actually conducted CER and [ indiscernible ] of all played big roles and payers especially societies and industry are -- industries and entrepreneurs have all have big stake. We have the next newest kids in town and we get to fund the next version of it and we're doing it with the strong support of everybody who's made investments to this point. The and to build a national patient center to improve the nation's capacity to -- to conduct CER efficiently and division is that this will really create the next step in building a US healthcare system and allow system and allow the deuced large scale research affordably in both clinical trials and observational studies and we demand one is a unique aspects of our announcement is we demand that these people who have access to the data within these large health systems bring their system leadership along. As I used to be just a researcher from Kaiser Permanente speaker -- speaking for myself and the research team. . We want to Bernard Tysons of Kaiser Permanente to be aware of the leaders of whatever systems wind up. This is the way the network will look. There will be eight clinical data research networks and those are those system these electronic health records base networks most of them will be partnership say delivery system and the health can -- plan hospital system and that practice base research. research group. We have applications from cities and states and safety next providers. The reviews have been done on this in already's will be named in December. I also want to mention the patient powered research network and this is really a novel idea that we became convinced was also crucial to making a difference. We are funding 18 patient organizations who have patients with a single condition and it may be diagnosis and it may be something like palliative care chronic pain but those are also part of the network and their job is to work their way into the large systems, activate the membership is within those large systems, teach the members from the large systems either to patient centered r esearch, participate in governing the network and I want to point out to you that arc as well as other funders and eight, FDA are on the steering committee, CMS is on the steering committee and the industry will also and it may not be shown there yet but industry has been cited -- invited to sit on the steering committee as a potential funder of research in this network. These guys look at 18 months a pretty generous funding after which we will have around two for those who succeed in meeting the requirements of getting up to speed of being able to participate in the network share data post trials and allow the excess from outside researchers to conduct research in the network. In the let -- and the last is our relationship. I said a bit of this at the beginning that I think PCORI needs a better way to define who we are and what we do as compared to what AHRQ does. We suspect art would find a need for the same. [ indiscernible ] responsibilities that we spent -- demonstrates that we're doing things, E fashion collaborating and that both are critically important to improving health and healthcare in the n ation. We want to to start by identifying a range of AHRQ currently mandated activities and our quite a bit narrower [ indiscernible ] in .2 and this still takes discussion, .2 overlapping areas that need careful discussion such as evidenced, dissemination and [ indiscernible ] activities. At this point, PCORI my understanding is AHRQ would agree we are the answer is authorized to fund comparative research including [ indiscernible ]. AHRQ has numerous mandates that PCORI does not share and it d'Este include but I bet I've left one off in and gene or others can remind me. Quality is not our [ indiscernible ] North patient safety or health IT aside from sending it to the use of research structure nor surveillance or data collection such as [ indiscernible ], nor is what I call knowledge management but all of the information on the website and the guidelines clearinghouse is one example. Your is workforce training and comparative effective research. That is mandated to arc in the legislation nor is technology assessment in your relationship to CMS. Those are many areas that AHRQ has responsibility we don't we need to figure out how to talk about that and really have to stay out of it. It's easy to get pulled into many of these directions. This is the way we see it that there is a bidirectional relationship between the two entities. On the left is the set of responsibilities and on the right is the single responsibility of PCORI which is conducting and supporting compared to effectiveness research, everything that you do generates comparative effectiveness research, questions every comparative effectiveness research question that we study and answer feedback to one or many of the functions that many of you oversee. There is a lot of rude -- room to be complementary and to collaborate.
These are three areas that strike me as having some overlap that we need to clarify. One is about evidence synthesis, arc has an amazing infrastructure and framework for formal evidence synthesis. PCORI has a mandate to support evidence synthesis and we have funding and needs and evidence synthesis. Sometimes I think our evidence synthesis needs are more narrow but sometimes they can be brought as well and it may come out of the advisory panel that is exactly what is needed evidence synthesis area. How to we collaborate and these clicks health IT is an area where we need to understand better AHRQ I'm going well in this area to Julie as it relates to the national patient centered clinical research network and I think having AHRQ on the steering committee that infrastructure will allow us to make sure that we keep our eyes on that in the asset -- the last is the most complicated and we are developing a dissemination and implementation plan right now. AHRQ is involved in the work group that is developing and that we talk about it at the board we have a whole committee that one of the board committees that it tends to that and I think over the next year we will nail down much more completely the complementary roles of our two agencies in this area. And that is the end of my remarks am anxious for questions.
Thank you very much. We really appreciate the time to come visit with us today. This is obviously been a topic of much discussion here's I'm curious to see most of the if any of our members have any comments up posted for Joe. Andrea, please.
Rick, you came this morning and presented your vision.
And presented your vision for arc -- for AHRQ if energized and we were happy to hear that and now Joe you are here we are very thankful you are here in the work you're doing is great too but now I must commit -- admit, little confused again. I'm sitting here into my mind mind I was start to simplify things. It's okay for AHRQ to do research if it's research that leads to improved outcomes because that's probably and improving quality and improving patient safety but it is PCORI the will to do research that compares one thing to another to see which is better. Does that make any sense? It certainly is our role to do the research like you described. Weather in the process of doing all the things that AHRQ does some of your studies cannot to be comparative is a different question and I don't think -- there were a lot of studies that were comparative before the term affair give effectiveness research came into Vogue.
[ Multiple speakers - indiscernible ]
What I presented this morning I did not say that it would be funding studies and whether surgery or watchful waiting is a better approach to do that. That's clearly PCORI.
Those in my mind are the easy ones.
[ Laughter ].
I don't think PCORI is going to be thinking about the impact of the ACA is one of the key priorities.
That is right.
[ Laughter ]
Or is Joe pointed out how to make hospitals and nursing homes in ambulatory care safer of the for priorities quality, safety, accessibility and affordability so the safety and accessibility priorities are pretty separate. Certainly PCORI has one of its purity the current disparities in disparities and accessibility and obviously overlap and to the extent that I am operationalizing accessibility in the short run is evaluating coverage expansion is quite separate. Affordability is a place for their it's some overlap because the CER questions ultimately are around resource use but as is Joe pointed out, PCORI has interest in health system issues which is a big part of the affordability priority but some overlap and a the Fairmont of separation as well. I think that first area of quality is the place where the overlap is greatest in the project I described are trying to out about how to disseminate PCORI in small and medium-size primary care practices may overlap some with projects that put Cory could potentially be interested in.
Let's do this. Let's go and mix directions. But go to Janet and then to David.
I appreciate the comment and point of clarification I have used it found very valuable the healthcare program within AHRQ and it clearly says I'm looking at the website now comparative effectiveness research for clinicians consumers and policymakers. Of those words migrate themselves out of AHRQ language? And I know other voluntary or professional associations of the American Academy Academy of the pit insurgents is just a wonderful analysis -- analysis the procedures as well as interventions for managing our see her arthritis of any in miniscule tears in the same sort of model of inclusive are conclusive moderately recommended therapies procedures and such so that often helpful for clinicians but I remain confused.
We will certainly continue to be in the business of synthesizing evidence for the EPC reviews that are done for the task force, for CMS, for PCORI is work that we will continue to do.
And that a so valuable the full sake it has not been disseminated as it needs to be among the nations and consumers as well.
And they just want to echo that to the extent that we do evidence synthesis it would likely be funding somebody such as the EPC network to do it. So I think that putting it up on the website afterwards so that people like you can use it is a part of dissemination and so that continues to fit it seems to me to fit squarely with AHRQ's mandate.
David?
First of all, Joe thank you for coming. And what to make comments opposed to questions. The first comment I want to make is that as we talk about demarcating responsibilities, I think it's going to be very, very efco is a researcher was funded by both of your organizations and who can point out parts of the projects which are squarely within AHRQ stemming and squarely within PCORI the main I think you're going to have a very difficult time of doing that the whole discussion about that defective healthcare program in the EPC system and is overlap and I think those are resources which I think are now or do developed and are can is a real danger in the process of demarcating responsibilities that some things get lost in the cracks. I don't know if my comment in this respect was to sort of caution I know now there are people in committees and they are most to be more than that RNA know that that's difficult in the legislation because I do worry that some of these really traffic programs at the ABCs are going to fall through the cracks and I am not of the opinion that there's enough evidence out there. Maybe I'm in the minority and the other piece I wanted to point out to you, Joe may be AHRQ can help here is there is an education piece is in our project we have not j ust -- we haven't -- brace the patient centerpiece which I never thought I personally could do with a surgeon and you know how searches pursue the stereotype and so it's an incredible. It's actually been an incredible thing that's also been a learning on the fly situation there's a tremendous need to train the next generation of researchers and frankly patients and this is something where ARC -- AHRQ can really help and I gets really and hearing you guys talk and crick your discussion this morning and Joe yours this afternoon I really want to you guys uys -- don't demark too much because your depth losing things in the cracks.
Michael, then gene.
Again, thank you for coming in. I've a comment in a question but I will start by echoing Andrea.
I appreciate the effort and is a patient I'm now more confused. Two things. One observation if I heard you correctly the quality is in the realm of AHRQ and PCORI doesn't do anything with quality?
We are not going to develop performance measures we evaluate that -- evaluate them.
Everybody does quality and I guess be careful the language and so forth and I think it's i mportant. I just want to focus suppression and dissemination as a clinician and some these tran2 -- I guess to questions. Oneness with dissemination, how do you define dissemination exit the getting information out there, is that assessing the uptake are further assessing the impact that the uptake is made because to me that is brought dissemination I'm interested for both AHRQ in PCORI and how we are measuring dissemination and it's their demarcation in those areas. As the second question is if because there is so much overlap there if we get the point where we're not sure -- that should was in charge I think what will be really helpful is what the process to determine is it PCORI director -- 10 trend -- PCORI directed AHRQ directed. As long as it's getting done in getting done well that would be helpful to be clear on that and those are two questions I'd be interested in your feedback on.
I'm not quick to take the bait try to define for you what is dissemination of where stops and switches to implementation. Dissemination is something that has to happen for information have b een.
That's ongoing to been.
Bets on when the Senate. One of the with which I totally agree with you in that just everything is interlocked is that we really think one of the most important dissemination strategies is to gauge engage the end users while research is going on. So that's that spoke put Cory does and I claim that that's done in the name of dissemination should be on that all I can say and let's see what access to its we don't intend to think about this or two develop dissemination plan without having AHRQ if the table. I agree with you that in the end we have to be able to say whose responsibilities are which. The other thing I will say is we think dissemination deserves more of the PCORI dollars as went to AHRQ in the slice that AHRQ got and AHRQ slice is really for workforce training and dissemination. What does that mean? Does that mean PCORI do some of the dissemination quickly divide up the work we do it puts does it mean that we send more money to AHRQ to do this dissemination. I think those kinds of discussions are part of developing and implementing the plan and they have to do it and they can do it better more efficiently and I will stop there.
I don't think I have much to add except in part the fall.-- on the new guy card and which still tend to figure this out and ask for your input and advice. Is Joe I think has in Janet pointed out even if you take the view that the shelf it somewhat empty and we need to fill out more as David was saying it is certainly the case that there is such men this amount of PCORI research that we know what should be done that's not getting done and that we don't know very well how to get that research used and understood. Excuse me. So there's plenty of work to do there. I certainly see it as [ indiscernible ] and priority one this morning as work that AHRQ should be doing but Joe's point that more and more resources here could be helpful certainly make sense as well some still trying to figure out how to make that work together in a way that kind of works both for the folks that are asking what's the relationship between you then also to actually get the work done in the show the results which is got to be in important part our focus.
The extra dollars is heartening prodigious want to make a plug to be sure that implementation of uptake and impact are part of what get done between the two organizations because I think for me that is where the [ indiscernible ] a row.
I will make one comment entered the gene about this. Figure coordination in understanding how you work together is really really important. I think those of you have been dealt things that we're not of your own creation and have diff -- very different histories and complex histories -- histories in PCORI with that up in a certain way in very differently for the way that AHRQ was set up and I don't want to rehash it all here. I think folks here trying to work the best with the been dealt not necessarily they would've designed a delete on their own the ambiguity will be there to some extent for while.
Thank you so much. I just finished doing my third PCORI review is a patient. I was thinking what a wonderfully rich source of information it would be because all of these grants that are going on with engaged patient to do follow-up with those engage these and to find out what was effective and what was not effective and how meaningful that engagement was. I am always struck by the need for public policy people on our panel and here because virtually everything we do is in the context of the society and Sophie so the just have researchers without that society present I think we're missing something. It seems to me we should all be talking about prevention instead of disease and we rarely can do that because the only thing we can fix is the disease.
This era.
Joe, it's been exciting to see the development of PCORI. You have really changed how we think about research and especially with the concept of partnership. I am very interested in some questions and comments related to that in the relationship between PCORI and AHRQ. One of the things in the AHRQ strategic plan and what you described about PCORI, Weathers overlap there are some things that are interesting but in particular Joe you mentioned kind of broad concepts and learning organization but then products like decision tools that are coming out of the research that's been done to accomplish the goals and the mission of PCORI. And some of this is fueled and fed by the evidence that AHRQ does in that all made sense to me. But one of the things that concern to me and maybe I am missing is a concept that fits in that sustainability and so with decision names and decision tools, we are ready have tools that need updating and these workflows that require constant updating and there are many in reaching out to people in their communities, patients and families and so forth to give them the information that they need to make help their decisions, this information needs to be constantly updated and the tools themselves as advancements are mean and informatics will be constantly updating the tools. Where the sustainability comment? Is that folded into dissemination?
I'm not so sure that often think about in my own approaching this, what is the business model that we should have for this.
I'm smiling because we just hit it to our meeting yesterday afternoon where we talked about this. One observation is that a lot of decision aides in decision support tools have been developed and yet there's not much evidence they are being widely used at one of the explanations and this notion that decision tools can get outdated shortly is vexing but true and t he second is that delivery s ystems, clinicians particularly active in patients are not presently incented or supported to use these tools. They exist but there is really know -- so what we're trying to do is develop active approach to managing a portfolio of these. We just don't want to cycle after cycle fund eight were decision-support tools wanted to find the [ indiscernible ] how the world you create an environment where people are motivated to use these tools in the first place. How do you motivate systems Tuesdays and within the system how do you Murphy clinicians and physicians. I think I would say six or nine months from now we will have a much more thoughtful approach and I will tell you we engage [ indiscernible ] and I will if imagine most most people no health Fox's and as a senior advisor and consultant precisely for this role and I think it ultimately does work its way to the AHRQ/PCORI dissemination ongoing discussion because you are right, the thing we are most afraid of is that we will indeed just keep funding and if we leave the present situation unchecked you can bet we will have a very large number of studies developing a very disparate group of decision-support tools.
And this is one of the things that could fall through the cracks between the two organizations as well.
And as you point out, if it were only the cracks between the two organizations --
A warm handoff.
It's actually I think much more is you point out what is the business case or what's the professional case?
Talk about that this morning about what kind of accountability systems are we going to have and imparts run the business case in part is having understanding from physicians and other clinicians if these tools actually two improve their ability to help the patients get better than nothing understand that I'm not there professionals and it's not just a business case. It's other cases but on the cracks in charioteer from CMS and some of the business cases around what pairs say with expect in the payer says they expect this then that creates a business need for it in the medical is the question what evidence does the payer have to say or is it the right thing for the. Actually say that in that is back to the evidence that we are collectively time to create.
Thank you.
Henning?
Joe, thank you very much for me and really eye-opening presentation and it made me think of certainly more questions and things I want to learn more about clearing the boundaries and shared work between the AHRQ and PCORI. I had up specific question and then perhaps a suggestion or comment offer the question is to require if you can offer off the top of your head any further detail about the 23 grants that were under the rubric of health disparities in terms of the scope and if you're aware of that information I'm curious to hear more about that. A lot of grants that we are supported with the other areas and they know it's very important area for peak work -- for PCORI.
I'm actually going to get a briefing on the addressing disparities folio in about 10 days. I wish I would've gotten it before he came here. We have a list of purity populations which is probably exactly like AHRQ's list but really we include in the world populations, Friel people patients with disabilities and all of those at a large numbers of those populations, particularly the world -- world populations are included and some of the funded research. I can tell you a few. There are several on tele-health enroll America. There is a project about mental health and role Arkansas and Arkansas the top. There is a project about lowering cardiovascular risk in Appalachia those are just three that come to mind that's very helpful and I'm lame I have as a representative of populations of both health professionals and is patients who identified patients who identify as actually minorities and in our allies and friends and family stepping said I'm recognizing that the health disparities this of DBT are still a very large burden for that population and hopefully one will be lifted so much be lifted somewhat so much for that easy and ObamaCare. There are wonderful opportunity certainly through PCORI, I believe there are one -- wonderful opportunities certainly with AHRQ and [ indiscernible ] with D r. Collins at the NIH to talk about opportunities to discuss sexual minorities in the health contexts and I would encourage AHRQ in PCORI to have coordinated the communication is the shared work is discussed that there key opportunities not just for this population the other targets of populations for need. These would be really opportunities to engage with the opportunities can come from as well as [ indiscernible ] for scratching their heads of the befuddled and thinking like if I had a research project and I am supervising resurrects -- several residents are grad students, freshness and the application? I need to get a better idea of that for myself to be able to lead them in the think this is a, question that would face many researchers and many different areas around health disparities around the country.
Appreciate the comment and I'll take it it back to her director in addressing disparities. I also refer you to the website. You will see we do have research hundred and addressing issues and sexual minorities and just to remind applicants that when they come to PCORI, at hear it -- it needs to be a comparative effectiveness -- effectiveness question. That's all.
This is a bit of a third rail one of the things that I'm really hopeful that you guys can collaborate on at the intersection of cost quality and safety and new coats coming into the healthcare system. You will never keep the research of every year there's 200 new technologies that are either CBT or [ indiscernible ] code that generate huge safety issues along metal hip replacements, [ indiscernible ] screws, drugs, vices and then we find out years later heard people I'm just wondering if this ever an appetite in Washington DC to say can we please get research on new technologies that enter the market under pools of your mission statements because she will never ever be able to keep up with it if the technologies a 300 a year end you are studying two or three every year. I know it's a third rail but I serve, [ indiscernible ] selection committee and I know that CMS is restricted to looking at evidence and cost and making coding decisions. I've tried to get evidence-based coding and CPT codes for Medicaid and mental health for five years unsuccessfully and so does anyway that you can figure out and I know the politics to get into the market a new coats and say we need to research to protect our consumers from this technology think you might have an opportunity to [ indiscernible ]. The just don't think you're going to be able to keep up with the market.
Sorry.
[ Multiple speakers - indiscernible ]
I may be enough of an academic to step on the third rail am not a politician but I think as we discussed PCORI has the brief to fund research that tries to figure out whether these new things work and whether they work better than the old things. AHRQ through the APCs does synthesis of evidence to the extent that the evidence actually exist to be able to provide an objective and credible summary of what is the evidence say about whether this thing works or not and CMS among others uses those syntheses in doing that national coverage determination because you point out the kind of part that some people might like to see and that is not explicitly in any of this is doesn't work at what cost so there may be some that works put in a sense that it produces some benefit at a very high cost, that as a place for some of the third rail is pretty live but I think the work that I've discussed this morning about trying to understand differences across health systems and how resources are used lose in that direction as in the direction of the work that a PIM is doing around choosing wisely so I don't think that either PCORI AHRQ is going to get into the cost benefit business anytime soon but I think that there is work that both agencies that move in the direction to try to make sure the that resources are used more effectively and more wisely.
And again I'm not saying cost benefit analysis and things thing safety analysis and what I've seen it work really well in DC here is in lung reduction surgery.
That was cool.
That was a phenomenal opportunity for us to say but that it ahead of us worth so it work critically poorly is in transplants with women with end-stage cancer three of which I transplanted it Stanford and they died. Just a forget ever get into the cold take a big deep press and from the safety aspect and I know the cost effectiveness -- but from a safety aspect think we have enough opportunity to protect our consumers.
I will done. First of all I just had to say something about the the the -- the comments about decision support. I want to change it's not the updating necessarily because I will tell you own personal experience and that because the [ indiscernible ] republished in 1984 is still is accurate as it was for predicting heart these however the business case. Is this case we but we prep something that could reduce unnecessary admissions to the ECU . Watermill in your this. Desperate with the same year the DOD's came out how to show hospitals how to reduce their most profitable admissions and doctors were used to decision-support either I think it's very important that there is business cases for this and even if you get them in EHR is an obvious other things I think that all -- although it may be an attractive you really want some of those stakeholders to understand business cases on your board and hopefully involved with the grants need to make the business case is that's how things work in this country. They have to be some over for somebody to get paid to do it. The other thing is a thank you but before get to my comment about the merging is I remember how I that was for patient centered outcomes research was given and I think you injure Institute have to become a minute for transforming health service research in this country. It sometimes these -- seems so slavishly make a Stuart but it's very important and it's actually politically, scientifically and personally and ethically it's all right and it's in the [ indiscernible ] at health service research are it's been painful but it's exactly right on an effect splitting into as you saw AHRQ which is a good thing. Which brings me now to the pleading between the two of them. You said that appeared of effective research is not a mandate of HR cube and that the responsibility with our AHRQ had on and first of a don't agree that. For so it's not in the legislative statute or any that -- anything like that but moreover NAH does work. Of effective research towards health related service research then AHRQ does or you will do in there's enough need for those kinds of things not to have it delimited the one agency. I think I think in a sense I totally understand why you're being asked those questions. We seen that from the very moment people talked about this and Institute but I think you have to not be taken down a path that makes it a need to define that as being separate one effective the things they should be doing frankly sometimes collaboratively and sometimes what might see the put it if things from different perspectives. Your perspective and NAH perspectives will always be slightly different. The should all be doing some comparative research and when you are looking at strategies and comparing them some of them will be around safety and quality to get on have deceptive side and sometimes we are looking at safety we're going to be comparing it. ARC in two different ways. I would not get too slavish about that distinction.
Thanks. That's life was actually manufactured right after Congress let you know that the side programs needed to shut down.
It was very congressionally motivated. We saw that. I couldn't agree with you more.
Any other comments or questions from our councilmembers? Great. Thank you very much. ( Pause ) in terms of opportunities is step up one of my board members adjustment to save the first o r second day. Was on the job is already attending to tran2 into the relationship and functioning as a board member so thinks it's a wonderful so far.
Thank you and shameless a ctually. The preview that. I would be happy to come back at any time if you have additional questions.
At this time we are now heading towards the wrap up here. First one to see if there's anybody who's. Who wishes to make public comment? Objective anybody signed up. Okay, seen on global freight to that. The last part of our agenda is the chairman's wrap and input from the Council.
With apologies, I need to run to an airplane an adjustment again thank you particularly the departing members for your work, not even particularly, departing members for your work and also the continuing members, I really look forward to your input and those of you who are on the snack erbium the snack and it's been a really useful day to hear your and get your suggestions and encourage you all know how to get in touch with me and sure we don't need only is this forum when you have advice or suggestions so please don't be bashful on that. And again just thank you very much for your supports and energy and advice both in the past to date and in the future.
Great day for me. So thank you.
With that said I would just make a couple comments and opened up for comments for all of you. Obviously we have had a bit of a -- it's been wonderful to have our new director here and I think obviously he will probably do is to differently from the directors before him have done them and I think I try to be cognizant of that and I suspect in the months ahead we will probably form a relationship with them that may have been different from Carolyn in terms of how the structured or what questions get asked in the following. One thing I would just say to all of you all in my colleagues is that as you think about the future meetings and you may be discussed that today and the future I think we have select cognizant of two things. One is a mentioned Dr. Chronic me ask us to way and things in different ways and under different structures as he did this morning filling out a set of priorities and a mission statement and asking for input on that and by being fairly specific about his asked to the subcommittee on strategic fractions and as we think about what we talk about in the future we want to cut said about that agenda -- agenda we will roll out and various ways and we may want to continue to provide input and that agenda both in terms of it's form is posted implementation and I think perhaps our future questions and our thoughts about your topics should reflect those priorities and reflect that dynamic of the new director put his imprint anything for effectively these early days on agency. So that said I will turn to my colleagues for any comments or suggestions before we wrap the Anders handbook first.
I just wanted for first say is my last meeting and have totally enjoyed this. I've learned from all of you and from any past members and learned in ways that have many times nothing to do with this but many times really forwarding what we all care about the scholarly medicine in this country. What I would challenge you and I don't figure be a problem with this because of the people remaining is that you keep the patient at the forefront and you think about that every time you thinking about something the matter how hard we try we can list that. We talk in the disparities about quick turnaround it is think it's something that PCORI and AHRQ, we have to take data as soon as we possibly get it turn it around and -- in the actual information that impacts patients. It's something that bothers me every time I come here. I don't have all the answers and I know it's difficult but it seems to me we can do this. If that is something that you could push toward a think it would be wonderful. And lastly the collaboration. It was interesting when you're listening on the head of the snack all of the different people, one of the strengths of this group is that we have a multitude of people with different backgrounds and ideas and many of us represent multitudes of, doctor but I'm also healthcare company posted and I've got a lot of different hats I wear here. I think that's really one of the strengths to because I can't get everybody run your table I think you should track so I don't know how the process goes for getting new members of the think you look into it you're making sure that you have nurses at the table and your PTAs at the table in you have different minority groups represented at the table that patients are absolutely sitting at the table. I really employee to keep that going and I Dr. Too would be bad either. It was a pleasure.
I will note I think that is a great comment and Janet me want to talk about that also. I will note that I think this is the first non-physician director AHRQ.
Okay. Take back. Nevermind. [ Laughter ].
Janet, I think maybe want to comment on this point?
Thank you so much that was delightful today to want to thank everyone for all of their input. It's been wonderful learning experience for me particularly your leadership and your staying to help [ indiscernible ] the next forward. It's a mixup providers I think it's really important as Rick talked about wanting to make sure to increase accessibility to care and access to providers and the data is pretty strong about the quality irrefutable quality provided by number of different other healthcare providers including nurse practitioners, PTAs and others and we won't be successful with it accountable care act the Institute of mashup -- Advent -- we need physicians and nurse assistants and we need to think about changes in delivery strategies that allow those people to really practice to the full extent of their training and knowledge skills but I hope that whoever make the decisions about membership will include folks that are evolving care. I'm excited about the opportunity to stay involved and perhaps strategic planning committee with my patient had the so -- hot on this time it's part is my work with your threaded foundation but I wanted to get everyone for the wonderful opportunity to serve and for all that you provided me way of learning. Thank you.
Thank you. I'm going to tran2 Harry next.
Probably known as rude enough to stay up to want to an obvious point that I think this is a much more productive type of meeting that we've had in the past. I think in the past with the strategy has been explicated would be by giving a whole scattershot of various different products -- projects and not have discussions about what we're doing. I guess I'm doing this is feedback for future meetings and they think this was much more productive and it actually seemed like it is an concert we were asked as if we had advice to give you want to encourage the opportunity for those kinds of conversations because just hearing about the project is that they are always great they are fantastic and I've learned from them it is not what we're here to do.
Thank you. Very well said and I would ask Jamie and others in this room and staff and I will do this also but to please reflect that comment. Comment on that, this is -- composition back to the director
Yes. We will certainly do that and as you can tell he is a different approach and I'm glad it's resonating with everyone else. And I will speak a little bit to the knack process. The types of providers and all those things are actually taking into account every time we have a full listen anybody coming off we make sure we are hitting on all those pieces. Not to worry we absolutely think about that.
I guess they want to take the opportunity as a graduating member also --
[ Laughter ]
Jo get your degree. It really has been a privilege and a pleasure to work with all of the colleagues here and those in the past and it produces guidance of this team I think is been invaluable and Jamie support and the rest of the staff has been great. I appreciate that the agency has this vehicle were input and I appreciate the opportunity to be here is Andrea said with different hats I'm, it pay for healthcare come up mostly for lower income income people they also represent people who provide health care. Not usually considered providers. There the nonprofessionals. I am really happy that AHRQ does have some in their sites because they are so vital to the patient experience and the delivery of quality care. If the floors are not mopped, it's not safe care, it's not care that the patient will enjoy. If the food is delivered hot, not going to be the patient experience so I urge all of you and arc and selecting and HHS and selecting future members of the knack to keep these folks in mind.
Thank you.
Other parting comments?
Another parting knack member but me also think everyone. This is been a terrific experience Bruce I can't say enough about your stewardship you are doing an outstanding job and just one thing I wanted to highlight was on the priorities Rick really emphasized patient safety and I have to say that I think it's really critical for arc to continue to highlight and one of the things they do on my day job is implementing bundled care any seals and a lot of it is pushing more care out of the hospital and I worry about patients in ambulatory area. I'm glad to hear that Rick highlight that is a pretty going forward and as others have said I hope to say connected through the knack. And it's great work here.
Thank you. Thank you for your contributions.
I will just say it's in honor to be on the AHRQ, I can say is one of the longest tenured medical directors and Medicaid it's been no small measure because of AHRQ. When I was in front of the paper the paths I could stand on really good evidence so I really appreciate all the time and hope that I can still say connected and and tighten stay on your mailing list. I think the tools are phenomenal BofA to agree agree, Bruce I am hopeful that more it you can them disseminated the more we can attain the tripling. So thank you.
And since I've had the privilege of working with all of you longer than [ indiscernible ] I will just say on behalf of Carolyn Andrick again thank you so much for your participation and I will say our knack is only as good as the applications that we get an we've had some stellar applicants over the years and as you said every year and April and May are Federal Register notice goes out and people can apply the we encourage you continue to make recommendations% people our way and as we always say you are always family and so you can't get too far weight and is always and opportunity to keep participating in think you again.
Seeing no further comments, it's been a great meeting. Thank you to all of you those departing and then coming back our next meeting. At April 4th here and we will look forward to seeing many of you then or in other venues. Have a safe trip home.
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